Every finding on record at Rise N Shine Hospice 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 Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) regarding the Patient’s Rights was met as follows:1. The HA failed to ensure the patient or representative, was provided with verbal and written notices regarding the patient's rights and responsibilities, in a language and manner that the patient would understand for two of 19 sampled patients. (Patient 4, and Patient 6). This failure had the potential of patients not understanding hospice services and purpose of hospice care that could negatively impact the patients’ quality of life and care. (Refer to L502). 2. The HA failed to ensure a completed copy of written information regarding advance directive (a legal document that outlines person's wishes in the event an individual is unable to express wishes for healthcare and treatments) policies and descriptions was provided for one of nineteen sampled patients (Patient 10).This failure had the potential to result in the patient’s family and/or caregivers not knowing what the patient’s medical decisions are, which can result in psychological distress to the patient/patient’s family/caregiver. (Refer to L503). 3. The HA failed to ensure a copy of patient’s rights and responsibilities were given to two of 19 sampled patients. (Patient 10 and Patient 15).This failure had the potential to result in patient and their family/caregivers not being aware of the patient rights and responsibilities. (refer to L504). 4. The HA failed to ensure to implement patient’s rights for effective pain management for one of 19 sampled patients (Patient 2) by failing to: a. Ensure HA licensed nurses conducted and documented the comprehensive and ongoing pain assessments for Patient 2, who had a generalized pain level of 9 of 10 on a numeric pain scale (zero meaning “no pain” and 10 meaning “the worst pain imaginable”) during home visits, in accordance with the HA’s own policies and procedures. b. Reevaluate and document accurately Patient 2’s pain level after an intervention on 1/3/2025, 3/14/2025, and 3/25/2025 to determine their effectiveness in relieving the pain.  c. Ensure has individualize Patient 2’s care plan for pain to reflect Patient 2’s history of no significant relief from acetaminophen (analgesic to relieve mild to moderate pain) and hydrocodone (opioid medication to treat moderate to severe pain). These failures resulted in Patient 2 with inadequate pain relief and being unable to eat due to pain. (refer to L512) 5.  The HA failed to ensure that access to the plan of care was provided and the right to be involved in developing a plan of care was upheld for three of 19 sampled patients. (Patient 4, Patient 6, and Patient 15). These failures had the potential to result in patient and/or their family member/caregiver being unable to be an active participant in his/her care. (Refer to L513).The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily (written law) mandated compliance with Federal regulation for Patient’s Rights to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits. --- 1. The HA failed to ensure the patient or representative, was provided with verbal and written notices regarding the patient's rights and responsibilities, in a language and manner that the patient would understand for two of 19 sampled patients. (Patient 4, and Patient 6). This failure had the potential of patients not understanding hospice services and purpose of hospice care that could negatively impact the patients’ quality of life and care. (Refer to L502). 2. The HA failed to ensure a completed copy of written information regarding advance directive (a legal document that outlines person's wishes in the event an individual is unable to express wishes for healthcare and treatments) policies and descriptions was provided for one of nineteen sampled patients (Patient 10).This failure had the potential to result in the patient’s family and/or caregivers not knowing what the patient’s medical decisions are, which can result in psychological distress to the patient/patient’s family/caregiver. (Refer to L503). 3. The HA failed to ensure a copy of patient’s rights and responsibilities were given to two of 19 sampled patients. (Patient 10 and Patient 15).This failure had the potential to result in patient and their family/caregivers not being aware of the patient rights and responsibilities. (refer to L504). 4. The HA failed to ensure the patients received the rights for effective pain management for one of 19 sampled patients (Patient 2) by failing to: a. Ensure HA licensed nurses conducted and documented the comprehensive and ongoing pain assessments for Patient 2, who had a generalized pain level of nine (9) of 10 during home visits, in accordance with the HA’s own policies and procedures. b. Reevaluate and document accurately Patient 2’s pain level after an intervention on 1/3/2025, 3/14/2025, and 3/25/2025 to determine their effectiveness in relieving the pain.  c. Ensure Patient 2 has individualized care plan to addressed Patient 2 has no significant relief from acetaminophen (analgesic to relieve mild to moderate pain) and hydrocodone (opioid medication to treat moderate to severe pain). These failures resulted in Patient 2 with inadequate pain relief and being unable to eat due to pain. (refer to L512). 5.  The HA failed to ensure that access to the plan of care was provided and the right to be involved in developing a plan of care was upheld for three of 19 sampled patients. (Patient 4, Patient 6, and Patient 15). These failures had the potential to result in patient and/or their family member/caregiver being unable to be an active participant in his/her care. (Refer to L513).The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily (written law) mandated compliance with Federal regulation for Patient’s Rights to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits.

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 patient or representative, was provided with verbal and written notices regarding the patient's rights and responsibilities, in a language and manner that the patient would understand for two of 19 sampled patients (Patient 4 and Patient 6).This failure had the potential of patients not understanding hospice services and purpose of hospice care that could negatively impact the patients’ quality of life and care. --- Findings:1. During a review of Patient 4’s medical form, titled “Personal Information,” the “Personal Information” indicated Patient 3’s Start of Care SOC date of 3/11/2025 with a primary diagnosis of Alzheimer’s disease with late onset (progressive mental deterioration in adults 65 years or older, leading to a decline in memory, thinking, and other cognitive functions). During a concurrent observation and interview on 6/4/2025 at 10 AM while on a joint home visit with Licensed Vocational Nurse (LVN) 3, LVN 3, who was fluent in her native language was observed communicating fluently with Patient 4 and Patient 4’s caregiver (PCG). PCG was observed asking for LVN 3’s direct phone number. LVN 3 stated PCG requested for LVN 3’s direct phone number because PCG could communicate better using the same language. LVN 3 stated LVN 3 was a HA contracted staff (individuals hired by an organization on a contact basis for a specific project or period of time) and it was her first time to conduct a home visit for Patient 4. LVN 3 stated PCG stated she did not know where the hospice binder was. During an interview on 6/6/2025 at 12:40 PM, the Administrator/DPCS stated the hospice binder must be readily “accessible and visible” in the patient’s home at all times for the patient, caregiver, and the HA staff. The Administrator/DPCS stated the hospice binder contains the documents that indicated important information, including the services the HA provides, patient rights, and plan of care. The Administrator/DPCS stated it would be a problem if the patient and the primary caregiver could not understand the information provided to them in the hospice binder. The Administrator/DPCS stated there was no documented evidence that a copy of the patient rights and responsibilities was provided to Patient 4 and/or Patient 4’s caregiver (PCG) in a language or manner that Patient 4 and/or PCG would understand. 2. During a review of Patient 6’s clinical record titled Personal Information undated, indicated a Start of Care (SOC) date of 12/18/2024, with a primary diagnosis of Acute ischemic heart disease (a group of conditions where there is sudden and significant decrease in blood flow to the heart muscle, often due to blockage in a coronary artery [the blood vessel that supplies oxygen rich blood to the heart muscle]). Patient 6’s Personal Information record also indicated the patient’s primary language.During a review of Patient 6’s clinical record titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 5/22/2025, indicated an order for Skilled Nurse (SN) visit frequency of one time per week to assess changes in condition, shortness of breath, pain and symptom management.During a joint home visit on 6/4/2025 at 1:05 pm with Licensed Vocational Nurse (LVN) 4, at Patient 6’s residence, Patient 6 was observed lying in bed on her right side, awake, alert and oriented to self, date, time and location and able to communicate in her native language. LVN 4 translated for Patient 6, and LVN 4 stated that Patient 6 stated she (Patient 6) only spoke her native language and did not speak, understand or read in English. LVN 4 translated for Patient 6, and Patient 6 stated she (Patient 6) lived with her daughter and son in law who also only speak the native language and do not speak, understand or read in English.During a concurrent interview and record review on 6/4/2025 at 1:45 pm with LVN 4, Patient 6’s HA folder was reviewed. Patient 6’s HA folder indicated a copy of Patient 6’s consents for treatment and patient rights that were in English wording. LVN  4 stated and confirmed Patient 6’s consent and patient rights forms from the HA were in English wording. LVN 4 translated for Patient 6, and Patient 6 stated that she (Patient 6) could not read the consent for treatment and patient rights forms. LVN 4 translated for Patient 6, and Patient 6 stated that she (Patient 6) did not have any other consent or patient rights forms from the HA in her native language wording and further stated that she (Patient 6) signed the consent and patient right forms with a staff from the HA with help from a translator used via phone call.During an interview on 6/5/2025 at 3:50 pm with Registered Nurse (RN) 2, RN 2 stated patient’s HA folders include copy of their consents, patient rights, information on contacting the HA, department of health number, a copy of their care plan. RN 2 stated if a patient does not speak, read or understand English but their primary caregiver does then if the patient permits it, they will provide them with consent and patient rights forms in English. RN 2 stated if a patient and their primary caregiver do not speak, understand or read in English then the patient and primary caregiver should be provided with consents and patient rights forms in their language they prefer. RN 2 stated the HA does have consents and patient rights forms in languages other than English that they could provide to the patients.During an interview on 6/6/2025 at 1:04 pm with the Administrator/Director of Patient Care Services (DPCS), the DPCS stated the HA patients were provided with consent forms and patient rights in a language that they understand. The DPCS stated if a patient speaks in their native language, then a booklet, consents and patient rights will be provided to them in a language they understand, and if a patient speaks a language that is not common then the HA will request from the printing company to provide booklet with consents, patient rights to be printed in that language. The DPCS stated if a patient speaks another language other than English, and the skilled nurse (SN) does not speak that language, then the SN should use a translator and document it on the visit notes what type of translator was used. The DPCS also stated the SN’s should inform her (DPCS) if any patients have language barriers to inform the care team and assess what are the patient’s communication needs.During a review of the HA’s undated policy and procedures (P&P), titled “Patient Bills of Rights,” the P&P indicated the following:1.      Upon admission, the admitting clinician/technician must provide each patient or his/her representative with a written copy of the Patient Bill of Rights.2.      The Patient Bill of Rights must be explained and distributed to the patient prior to the initiation of organization services in a language he/she could “reasonably be expected to understand.”3.      The admitting clinician must document that the patient has received a copy of the Patient Bill of Rights. If the patient was unable to understand his/her rights and responsibilities, documentation in the clinical note must be made. In the event that a communication barrier exists, if possible, special devices or interpreters must be made available. Written information must be provided to patients in the predominant languages of the population served.

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 a completed copy of written information regarding advance directive (a legal document that outlines person's wishes in the event an individual is unable to express wishes for healthcare and treatments) policies and descriptions was provided for one of nineteen sampled patients (Patient 10).This failure had the potential to result in the patient’s family and/or caregivers not knowing what the patient’s medical decisions were, which can result in psychological distress to the patient/patient’s family/caregiver. --- Findings:During a review of Patient 10’s clinical record titled Personal Information, undated, the Personal Information indicated a start of care (SOC) date of 5/2/2025, with a primary diagnosis of acute ischemic heart disease (a sudden, severe reduction in blood flow to the heart muscle, leading to a lack of oxygen and nutrients).During a review of Patient 10’s clinical record titled Plan of Care/Interdisciplinary Group Review (POC/IDG Review, a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 5/19/2025 indicated, an order for Skilled Nurse visit frequency of one time a week and one as needed (PRN) visit to assess changes of condition, shortness of breath, promote comfort, and pain and symptom management.During a review of Patient 10’s clinical record titled Current Treatment/Medication/DME (Durable Medical Equipment) List, undated, indicated, an order date of 5/2/2025 and start date of 5/2/2025 Code Status: DNR (Do Not Resuscitate, it is a medical order that instructs healthcare providers not to perform cardiopulmonary resuscitation (CPR, an emergency treatment that is done when a person’s  breathing or heartbeat has stopped) if the patient's heart stops or breathing ceases).During a home visit observation on 6/4/2025, at 11:10 a.m., to Patient 10’s residence, with Registered Nurse (RN) 1, Patient 10 was observed resting comfortably on her chair. Patient 10 is alert, awake and oriented to her name, time, place and events. During a concurrent interview and  review of Patient 10’s hospice folder with RN1, The folder had the name of the agency, inside of the folder indicated no copy of Patient 10’s POLST (Physician Orders for Life-Sustaining Treatment, is a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness). During interview with RN 1, stated she was unaware that Patient 10’s POLST was not inside the hospice folder or anywhere in her residence. RN 1 stated that the POLST should always be with the patient, and it should have been check and processed by the social worker. RN 1 stated that if Patient 10’s heartbeat stops, then a CPR must perform since the POLST was not with the patient. During an interview at 11:45 a.m., with Patient 10, Patient 10 stated she does not remember if she has a copy of the POLST. Patient 10 stated she does not remember if a POLST was discussed and explained to them by the HA.During a concurrent interview and record review on 6/6/2025 at 12:45 p.m., with the Director of Patient Care Services (DPCS), indicated Patient 10’s POLST was completed but was unsure why a copy was not in Patient 10’s folder or residence. DPCS confirmed that Patient 10’s POLST, dated 5/2/2025, is complete and signed, DPCS stated that a completed copy should have been provided to Patient 10’s hospice agency’s home folder for future reference to define the code status of the patient. During a review of the HA’s policy and procedure (P&P) titled, “Advanced Directives,” undated, the policy and procedure indicated that: 1. Upon admission, the clinician/technician will provide information regarding a patient's right to make decisions concerning health care, which include the right to accept or refuse medical or surgical treatment, even if that treatment is life-sustaining, the right to execute Advance Directives, and applicable organization policies.  Written information designed for this purpose will be provided to the adult patient.  The clinician/technician will document in the clinical/service record that the information was provided and document all discussions concerning Advance Directives.

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 a copy of the patient’s rights and responsibilities were given to two of 19 sampled patients. (Patient 10 and Patient 15).  This failure had the potential to result in Patient 10, Patient 15 and their family/caregivers not being aware of the patient rights and responsibilities. --- Findings:a. During a review of Patient 10’s clinical record titled Personal Information, undated, the Personal Information indicated a start of care (SOC) date of 5/2/2025, with a primary diagnosis of acute ischemic heart disease (a sudden, severe reduction in blood flow to the heart muscle, leading to a lack of oxygen and nutrients), unspecified. During a review of Patient 10’s clinical record titled Plan of Care/Interdisciplinary Group Review (POC/IDG Review, a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 5/19/2025 indicated, an order for Skilled Nurse visit frequency of one time a week and one as needed (PRN) visit to assess changes of condition, shortness of breath, promote comfort, and pain and symptom management. During a home visit observation on 6/4/2025 at 11:10 a.m., at Patient 10’s residence, with Registered Nurse (RN) 1, Patient 10 was observed resting comfortably on her chair. Patient 10 was alert, awake and oriented to her name, time, place and events. During a concurrent interview and  review of Patient 10’s hospice folder with RN 1, the folder had the name of the agency, inside of the folder indicated no copy of a signed patient’s rights and responsibilities (fundamental aspect of healthcare, ensuring both a patient's well-being and their participation in the healthcare process, patients have the right to informed decision-making, including refusing or requesting treatment, while also being responsible for providing accurate information and cooperating with their care plan). During interview with RN 1, stated she was unaware that Patient 10’s signed copy of patient’s rights and responsibilities was not inside the hospice folder or anywhere in her residence. RN 1 stated that s copy of signed patient’s rights/responsibilities should be included in the folder for patient’s reference. During an interview at 11:45 a.m., with Patient 10, Patient 10 stated she signed some documents but does not remember if she has a copy of it. Patient 10 stated she was aware of her rights as a patient, stated it would be better if she has a copy to review of her rights and responsibilities as a patient. During a concurrent interview and record review on 6/6/2025 at 12:45 p.m., with the Director of Patient Care Services (DPCS), Patient 10’s Patient Rights and responsibilities were reviewed. Patient 10’s copy of patient’s rights and responsibilities indicated it was signed and completed. The DPCS but was unsure why a copy was not in Patient 10’s folder or residence. DPCS confirmed that Patient 10’s rights and responsibilities, dated 5/2/2025, was completed and signed, however, the admitting clinician did not document that a copy was provided to Patient 10. DPCS stated that a completed copy should have been provided to Patient 10’s hospice agency’s home folder for patient’s reference of her rights and responsibilities.b. During a review of Patient 15’s “admission record” it indicated a start of care (SOC) date of 11/16/2023 with a terminal diagnosis of Alzheimer’s Disease is a progressive disease that alters one’s ability to think and remember things clearly, it progressively gets worse over time.During a review of Patient 15’s “plan of care summary” dated 6/6/25 it indicated the frequency of visits of skilled nursing (SN) was one (1) per week, and Health Aide visits of (HA) one (1) per week.During an interview with LVN 3 on 6/4/2025 at 2:15p.m. she stated that this was her first visit with this patient. She stated that patient 15 has been with agency for nearly 18 months. Caregiver stated that she’s employed to care for patient 15 either 5 or 6 days a week for the last year. She stated she has not seen a folder from the agency since she has started over a year ago. No folder located in home during visit.During a review of the HA’s policy and procedure (P&P) titled, “Patient Bill of Rights,” undated, the policy and procedure indicated that: 2. Upon admission, the admitting clinician/technician will provide each patient or his/her representative with a written copy of the Patient Bill of Rights.4.  The patient will be requested to sign the Patient Bill of Rights form. The original form will be kept in the patient's clinical record. A copy will be maintained by the patient. The patient's refusal to sign will be documented in the clinical record, including the reason for refusal.5.   The admitting clinician will document that the patient has received a copy of the Patient Bill of Rights.A. If the patient is unable to understand his/her rights and responsibilities, documentation in the clinical note will be made.B. In the event a communication barrier exists, if possible, special devices or interpreters will be made available.C. Written information will be provided to patients in the predominant languages of the population served. During a review of the agency’s policy entitled” Admission Criteria and process” indicated a hospice registered nurse will make an initial contact prior to the patient’s hospital discharge. The purpose of the initial visit will be to:a) Explain the hospice philosophy and palliative care with the patient and family/caregiver as a unit of care.b) Explain the patient rights and responsibilities and grievance procedures (see patient bill of rights)c) Provide the patient with a copy of Rise N Shine Hospice notice of privacy practice.d) Contact information to Hospice staff, POLST information, and current POC and MAR.

Based on interviews 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 to implement patient’s rights for effective pain management for one of 19 sampled patients (Patient 2) by failing to:   a. Ensure HA licensed nurses conducted and documented the comprehensive and ongoing pain assessments for Patient 2, who had a generalized pain level of 9 of 10 on a numeric pain scale (zero meaning “no pain” and 10 meaning “the worst pain imaginable”) during home visits, in accordance with the HA’s own policies and procedures.   b. Reevaluate and document accurately Patient 2’s pain level after an intervention on 1/3/2025, 3/14/2025, and 3/25/2025 to determine their effectiveness in relieving the pain.    c. Ensure has individualize Patient 2’s care plan for pain to reflect Patient 2’s history of no significant relief from acetaminophen (analgesic to relieve mild to moderate pain) and hydrocodone (opioid medication to treat moderate to severe pain).   These failures resulted Patient 2 with inadequate pain relief and being unable to eat due to pain. --- Findings:  During a review of Patient 2’s medical form, titled “Personal Information,” the “Personal Information” indicated Patient 2’s Start of Care (SOC) on 1/3/2025 and End of Care (EOC) on 4/16/2025 with a primary diagnosis of malignant neoplasm of mandible (jaw/jawbone cancer).   During a review of Patient 2’s History and Physical Examination (H&P), dated 8/24/2024, the H&P indicated Patient 2 had a “history of mandibular squamous carcinoma (most common type of oral cancer) who came to the hospital with failure to thrive (FTT, syndrome of progressive decline in physical and/or mental function in adults).” The H&P indicated Patient 2 had “previous tooth extractions which have shown atypical squamous cell hyperplasia (ASCH, abnormal growth of flat, scale-like cells that make up the outer layer of the skin and other tissues with atypical characteristics).” The H&P indicated Patient 2 had been “taking Tylenol (pain medication) and hydrocodone without significant relief.” The H&P indicated Patient 2’s physical examination of the Head, Eyes, Ears, Nose, and Throat (HEENT) was “notable for teeth removed from lower jaw with poor healing.”    During a review of Patient 2’s Comprehensive Nursing Assessment, dated 1/3/2025, the Comprehensive Nursing Assessment indicated Patient 2 was awake, alert, and oriented to time, place, and self. The Comprehensive Nursing Assessment indicated Patient 2 was “restless,” “depressed,” and experiencing “fatigue.” The Comprehensive Nursing Assessment indicated Patient 2 was “uncomfortable because of pain” and had a blood pressure of 172/98 (abnormally high) and a heart rate of 81 beats per minute. The Comprehensive Nursing Assessment indicated Patient 2’s oral cavity was “normal.” The Comprehensive Nursing Assessment indicated Patient 2 had 6/10 lower back pain and Patient 2 was instructed by Registered Nurse 1 (RN 1) to take Norco (pain medication combination of acetaminophen and opioid hydrocodone) 5 milligrams-325 milligrams tablet. The Comprehensive Nursing Assessment indicated RN 1 encouraged Patient 2’s caregiver to “gently massage patient’s affected area to reduce discomfort.” The Comprehensive Nursing Assessment indicated RN 1 educated Patient 2 non-pharmacological techniques, which would “help to make her condition better, such as rest, relaxation, etc.”   During a review of Patient 2’s POC/IDG Review, dated 1/3/2025, the POC/IDG review indicated the following pain interventions: 1.     Patient 2 was prescribed acetaminophen 160 milligrams orally every 8 hours for pain, aspirin 81 milligrams chewable tablet orally daily for pain, and Norco 5 milligram-325 milligram tablet orally every 6 hours as needed for pain. 2.     Skilled Nurse to report to the physician for pain greater than 5/10 and not relieved with rest and current prescription pain medications. The plan was to provide symptoms management, pain control and comfort measures. 3.     Plan of care (POC) for “generalized body pain” indicated the goal to “bring down pain to less than 3 or within the patient’s tolerable level (2/10) for comfort within 48 hours of admission.” POC indicated interventions included a) Instructing the family/PCG to give pain medications when pain level is greater than 2 or above, b) instruct on non-pharmacological methods of pain and symptom relief of repositioning, music therapy and/or calm, quiet environment, and c) administering acetaminophen and Norco tablet for pain as prescribed.    During a review of Patient 2’s Visit Notes, dated 1/10/2025, 1/17/2025, 1/24/2025, 1/31/2025, 2/7/2025, 2/14/2025, 2/21/2025, 2/28/2025, and 3/7/2025, the Visit Notes (VNs) indicated LVN 1 conducted the nursing home visits, but the HA Owner electronically signed Patient 2’s VNs “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation).    During a review of Patient 2’s Visit Note, dated 3/14/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s VNs on 4/1/2025 “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 5/10 pain and “pain patch is not helping.”    During a review of Patient 2’s Visit Note, dated 3/28/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s VNs on 4/1/2025 “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 5/10 pain on multiple sites.     During a review of Patient 2’s Discharge Summary, dated 4/16/2025, the Discharge Summary indicated “Patient/family have elected to revoke hospice services at this time to seek further aggressive treatment.”    During an interview on 6/5/2025 at 12:12 PM, Patient 2’s Family Member (FM 1) stated HA licensed nurses did not properly assess Patient 2’s jaw area swelling and pain level while Patient 2 was under their care. FM 1 stated Patient 2 developed multiple abscesses in the lower jaw area, which required hospitalization. FM 1 stated Patient 2 was “in so much pain, but nobody seemed to care and there was no pain relief.” FM 1 stated Patient 2 “could not eat because of the pain.”    During an interview on 6/5/2025 at 1:08 PM, Licensed Vocational Nurse (LVN) 1 stated Patient 2 always had pain level of 8/10 or 9/10 during the nursing home visits. LVN 1 stated Patient 2 had swelling to the left jaw upon admission and the swelling got “a little bigger” after a few weeks. LVN 1 stated she documented her assessments on Patient 2’s electronic health records. LVN 1 stated she did not know why the Visit Notes did not reflect the pain level and the swelling to the left jaw.   During a concurrent interview and record review on 6/6/2025 at 12:08 PM with the Administrator/Director of Patient Care Services (DPCS), Patient 2’s Visit Notes were reviewed. The Administrator/DPCS stated there was no documented evidence of Patient 2’s pain level of 8/10 and 9/10 and left jaw swelling. The Administrator/DPCS stated the pain level must be assessed by the licensed nurse at every home visit. The Administrator/DPCS stated if the patient has pain, the licensed nurse could administer the pain medication and observe the patient for about 30 minutes to an hour to reassess the pain level. The Administrator/DPCS stated if the pain was still uncontrolled, the licensed nurse must notify the physician if the patient would need an order for a breakthrough pain medication. The Administrator/DPCS stated it was important to take and document the patient’s vital signs at every home visit, because the HA staff need to “see the direction where the patient is going (improve or decline).”    During a concurrent interview and record review on 6/6/2025 at 3:41 PM, the Administrator/DPCS stated Patient 2 was “adamant that pain pills were not going to help her.” The Administrator/DPCS stated the Visit Note, dated 3/25/2025, indicated Patient 2 “had already taken her pain medication and pain patch was applied but she is still complaining of continuous pain.” The Administrator/DPCS stated Patient 2’s care plan for pain was not individualized and did not include the use of pain patch and to address issues with hydrocodone and acetaminophen not providing significant pain relief, opioids causing Patient 2 bowel problems, and Patient 2’s history of chronic marijuana use, to ensure effective pain management.   During a review of the HA’s undated policy and procedures (P&P 1), titled “Patient Bill of Rights,” P&P 1 indicated the patient has the right to receive effective pain and symptom management for conditions related to the terminal illness(es).    During a review of the HA’s undated policy and procedures (P&P 2), titled “Pain Assessment,” P&P 2 indicated the following:   1.     During the initial assessment and on an ongoing basis, the patient must be asked a general screening question regarding current or recent pain as part of the baseline data. Clinicians must consider the patient’s personal, cultural, spiritual, and ethnic beliefs when assessing pain or discomfort. 2.     When the patient or the clinician identifies pain, the following in-depth pain assessment information must be obtained whenever possible: a) pain intensity using a rating scale and the patient must be reassessed every visit for the existence and intensity of pain and the effectiveness of interventions to relieve pain; b) pain location, c) pain quality, patterns of radiation, and character, d) pain onset, duration, variations, and patterns; and e) alleviating and aggravating factors;  f) present pain management regimen and effectiveness; and g) pain management history, to include a medication history, presence of common barriers to reporting pain and using analgesics, past interventions and response, and manner of expressing pain. 3.     Effects of pain, including impact on daily life, function, sleep, appetite, relationships with others, emotions, concentration, etc. 4.     The patients/family’s pain goal and satisfaction with goal, including pain intensity and goals related to function, activities, and quality of life. 5.     Physical exam or observation of the site of pain.   During a review of the HA’s undated policy and procedures (P&P 3), titled “Ongoing Assessments,” P&P 3 indicated the following: 1.     The nurse must assess the patient on each visit for a) pain, including the origin, location, duration, severity, and relief measures, b) factors that alleviate or exacerbate physical symptoms, c) current treatment related to the identified symptoms and the patient’s response, d) vital signs appropriate to the patient’s condition, e) skin integrity, f) progress towards hospice goals and patient needs and problems, and g) compliance with treatments and medication regimen. 2.     Ongoing comprehensive assessments should focus on a) patient’s response to care, b) changes in patient’s condition, level of deterioration, c) changes in patient diagnoses/prognosis, and d) changes in the patient’s care environment or support systems. 3.     Based on the assessments, the plan of care—including problems, needs, goals, and outcomes—must be reviewed and update by the IDG members responsible for the case.

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 that access to the plan of care was provided and the right to be involved in developing a plan of care was upheld for three of 19 sampled patients. (Patient 4, Patient 6, and Patient 15). These failures had the potential to result in patient and/or their family member/caregiver being unable to be an active participant in his/her care. --- Findings:1. During a review of Patient 4’s medical form, titled “Personal Information,” the “Personal Information” indicated Patient 3’s Start of Care SOC date of 3/11/2025 with a primary diagnosis of Alzheimer’s disease with late onset (progressive mental deterioration in adults 65 years or older, leading to a decline in memory, thinking, and other cognitive functions). During a concurrent observation and interview on 6/4/2025 at 10 AM while on a joint home visit with Licensed Vocational Nurse (LVN) 3, LVN 3, who was fluent in her native language was observed communicating fluently with Patient 2 and Patient 2’s caregiver (PCG). PCG was observed asking for LVN 3’s direct phone number. LVN 3 stated PCG requested for LVN 3’s direct phone number because PCG could communicate better using the same language. LVN 3 stated LVN 3 was a HA contracted staff (individuals hired by an organization on a contact basis for a specific project or period of time) and it was her first time to conduct a home visit for Patient 2. LVN 3 stated PCG stated she did not know where the hospice binder was. LVN 3 did not have a copy of the plan of care for Patient 2 or PCG.During an interview on 6/6/2025 at 12:40 PM, the Administrator/DPCS stated the hospice binder must be readily “accessible and visible” in the patient’s home at all times for the patient, caregiver, and the HA staff. The Administrator/DPCS stated the hospice binder contains the documents that indicate important information, including the services the HA provides, patient rights, and plan of care. The Administrator/DPCS stated it would be a problem if the patient and the primary caregiver could not understand the information provided to them in the hospice binder.2. During a review of Patient 6’s clinical record titled Personal Information undated, indicated a Start of Care (SOC) date of 12/18/2024, with a primary diagnosis of Acute ischemic heart disease (a group of conditions where there is sudden and significant decrease in blood flow to the heart muscle, often due to blockage in a coronary artery [the blood vessel that supplies oxygen rich blood to the heart muscle]). Patient 6’s Personal Information record also indicated the patient’s primary language.During a review of Patient 6’s clinical record titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 5/22/2025, indicated an order for Skilled Nurse (SN) visit frequency of one time per week to assess changes in condition, shortness of breath, pain and symptom management.During a joint home visit on 6/4/2025 at 1:05pm with Licensed Vocational Nurse 4 (LVN4), at Patient 6’s residence, Patient 6 was observed lying in bed on her right side, awake, alert and oriented to self, date, time and location and able to communicate in her native language. Patient 6 was observed able to move herself side to side in bed and lift herself up to a sitting position in bed, in a slow pace. LVN 4 translated for Patient 6, and LVN4 stated that Patient 6 stated she (Patient 6) only spoke her native language and did not speak, understand or read in English. LVN 4 translated for Patient 6, and Patient 6 stated she (Patient 6) lives with her daughter and son in law who also only speak her native language and do not speak, understand or read in English.During a concurrent interview and record review on 6/4/2025 at 1:45pm with LVN4, Patient 6’s HA folder was reviewed. Patient 6’s HA folder indicated no evidence of a copy of the patient’s Plan of Care (POC) or medication list. LVN4 stated and confirmed Patient 6 did not have a POC or medication list in their HA folder. LVN4 stated every patient should have a copy of their POC and medication list provided to them.During a joint home visit on 6/4/2025 at 1:50pm with LVN4, at Patient 6’s residence, LVN4 translated for Patient 6, and Patient 6 stated that she (Patient 6) did not have a copy of her POC or medication list. LVN 4 translated for Patient 6, and Patient 6 stated since being with the HA she had not received a copy of her POC or list of medications. LVN4 translated for Patient 6, and Patient 6 stated that whatever was in the HA folder was what she was given by the HA. LVN4 translated for Patient 6, and Patient 6 stated that she (Patient 6) did not have a list of her medication, but she had all her medications together in a plastic container box in her room.3. During a review of Patient 15’s “admission record” it indicated a start of care (SOC) date of 11/16/2023 with a terminal diagnosis of Alzheimer’s Disease is a progressive disease that alters one’s ability to think and remember things clearly, it progressively gets worse over time. During a review of Patient 15’s “plan of care summary” dated 6/6/25 it indicated the frequency of visits of skilled nursing (SN) is 1 per week, and Health Aide visits of (HA) 1 per week.During an interview with LVN 3 on 6/4/2025 at 2:15pm she stated that this was her first visit with this patient. She stated that patient 15 has been with agency for nearly 18 months. Caregiver stated that she’s employed to care for patient 15 either 5 or 6 days a week for the last year. She stated she has not seen a folder from the agency since she has started over a year ago and no copy of the plan of care. No folder or copy of the plan of care located in home during visit.During a review of the HA’s undated policy and procedures (P&P), titled “Patient Bills of Rights,” the P&P indicated the following:1.     The purpose of the P&P was to encourage awareness of the patient rights, to provide guidelines to assist patients in making decisions regarding care, and to support active participation in care planning.2.     Each patient and/or patient representative must be an active, informed participant in his/her plan of care by empowering him/her with certain rights.3.     To assist with fully understanding patient rights, all policies must be available to the organization personnel, the patient, and his/her representatives as well as other organizations and the interested public.4.     The patient has the right to be advised in advance of the right to participate in planning the care or service and in planning changes in the care and service.During a review of the agency’s policy entitled” Admission Criteria and process” indicated a hospice registered nurse will make an initial contact prior to the patient’s hospital discharge. The purpose of the initial visit will be to:a)     Explain the hospice philosophy and palliative care with the patient and family/caregiver as a unit of care.b)    Explain the patient rights and responsibilities and grievance procedures (see patient bill of rights)c)     Provide the patient with a copy of Rise N Shine Hospice notice of privacy practice.d)    Contact information to Hospice staff, POLST information, and current POC and MAR.

Based on observation, interview and record review, the Hospice Agency (HA, agency who provides specialized care and support for people with a serious illness who are nearing the end of life) failed to ensure the Conditions of Participations regarding Initial and Comprehensive Assessments of Patients were met as followed: --- 1.      The HA failed to conduct and document an initial comprehensive assessment (an evaluation of the patient's physical, psychosocial, mental, social, and spiritual aspects, and emotional status related to the terminal illness (illness with a prognosis of having six months of life or less to live)) that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for two of nineteen sampled  patients (Patient 15, and Patient 17).This deficient practice had the potential to cause delay of patient care, uncontrolled patient pain, and undetected signs of physical, emotional, and spiritual needs when transitioning to final stages of dying process. (Refer to L522).2.      The HA   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)  failed to complete the comprehensive assessment to identify the patient/family’s physical, psychosocial, emotional, and spiritual needs within 5 calendar days of hospice care election for five of nineteen sampled patients (Patient 3, Patient 4, Patient 6, and Patient 10, Patient 14).This deficient practice had the potential to result inaccurate assessment to appropriately address patient’s psychosocial and spiritual needs which resulted in delay in formulating the plan of care to address the patient’s psychosocial and spiritual needs. (Refer to L523).3.      The HA failed to review all the medications and update the medication profile with the currently used medications for two of nineteen sampled patients (Patient 10 and Patient 15).This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. (Refer to L530).4.      The HA failed to ensure an initial bereavement (is the physical and mental impact of losing a loved one) assessment was completed for three of nineteen sampled patients (Patient 3, Patient 6, and Patient 14).This failure had the potential to result in placing the patient and family/caregiver at risk of spiritual, emotional distress and to impact a family members' abilities to cope with the patients' death. (Refer to L531). 5.      The HA failed to conduct an accurate and updated comprehensive assessment that reflected the patient’s current health status in relation to terminal diagnosis for two of nineteen sampled patients (Patient 2, and Patient 11).This deficient practice had the potential to result inaccurate assessment to appropriately address patient’s needs. (Refer to L533). The cumulative effect of these systemic practice resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with Federal regulation for Initial and Comprehensive Assessment of the patients to ensure the highest quality of care were being provided to patients certified to receive the hospice benefits.

Based on interview and record review, the Hospice Agency (HA- agency who provides specialized care and support for people with a serious illness who are nearing the end of life) failed to conduct and document an initial comprehensive assessment (an evaluation of the patient's physical, psychosocial, mental, social, and spiritual aspects, and emotional status related to the terminal illness [illness with a prognosis of having six months of life or less to live]) that reflected the patient's current health status and identify patient's need for hospice care and services related to hospice eligibility and management of terminal illness for two of nineteen sampled  patients (Patient 15, and Patient 17).This deficient practice had the potential to cause delay of patient care, uncontrolled patient pain, and undetected signs of physical, emotional, and spiritual needs when transitioning to final stages of dying process. --- Findings:a. During a review of Patient 15’s “Admission Record,” the record indicated Patient 15's start of care (SOC) was on 11/16/2023, with a terminal diagnoses of Alzheimer's Disease (a progressive disease that alters ones ability to think and remember things clearly, it progressively gets worse over time). During a review of Patient 15’s "Comprehensive Nursing Assessment," dated 11/16/2023, the assessment indicated under the vitals and measurement section, Patient 15's height (Ht), weight (Wt), mid arm circumference (MAC), and body mass index (BMI) were left blank and not assessed. During an interview on 6/6/2025 at 1:30pm with the Director of Patient Care Services (DPCS), the DPCS stated it was extremely important to obtain the patient's Ht, Wt, MAC, and BMI on initial assessment as it will be used to assess the patient's condition and monitor for the decline of the patient's condition. b. During a review of Patient 17’s “Admission Record, the record indicated Patient 17's SOC was 2/10/2025, with diagnoses that included Dorsalgia (pain in various regions of the back including the upper, middle, or lower back).During a review of Patient 17’s "Comprehensive Nursing Assessment,"  dated 2/10/2025, the assessment indicated under the vitals and measurement section, Patient 15's Ht, Wt, MAC, and BMI were left blank and not assessed. During an interview on 6/6/2025 at 1:30pm with the Director of Patient Care Services (DPCS), the DPCS stated it was extremely important to obtain the patient's Ht, Wt, MAC, and BMI on initial assessment as it will be used to assess the patient's condition and monitor for the decline of the patient's condition.During a review of the HA's Policy and Procedure (P&P) titled "Comprehensive Assessment," undated, the P&P indicated, "A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with attending physician. During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record..."

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Interdisciplinary Group (IDG, composed of a Registered Nurse [RN], Medical Social Worker [MSW], Chaplain, Physician [MD] who meet regularly to discuss the patients’ plan of care in order to provide the best individualized care and support patient and families) completed an accurate comprehensive assessment (to identify the psychosocial and spiritual needs) for five of 12 sampled patients (Patients 3, Patient 4, Patient 6, Patient 10, and Patient 14) when: 1. For Patient 3, Patient 6, and Patient 14, the Chaplain conducted an initial spiritual assessment within 5 days after the patients' start of care (SOC) date. 2. For Patient 4, and Patient 10, the MSW conducted an initial psychosocial assessment within 5 days after the patients' SOC date.These failures had the potential to result in the patients' decline of well-being as a result of incomplete assessment of the spiritual and psychosocial needs of the patients. --- Findings: a. During a review of Patient 3’s “Personal Information,” the record indicated Patient 3’s Start of Care (SOC) was on 4/23/2025, with a primary diagnosis of prostate cancer.During a review of Patient 3’s “Plan of Care/ Interdisciplinary Group (POC/IDG) Review (a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors),” dated 4/23/2025, the review indicated, “Spiritual Counselor (SC) would do initial assessment to provide spiritual support to patient and family. May conduct telehealth visits if it is feasible and appropriate to do so.”During a concurrent interview and record review, on 6/6/2025 at 1:01 PM, with the Director of Patient Care Services (DPCS), Patient 3’s electronic health records was reviewed. The DPCS stated there was no documented evidence that Patient 3 had an initial spiritual assessment done by the Chaplain. The DPCS stated Patient 3’s “POC/IDG Review” notes, dated 4/23/2025, 5/5/2025, and 5/19/2025 did not have a Chaplain's signature.During an interview on 6/6/2025 at 1:01 PM, the DPCS stated it was important for the Chaplain to attend the IDG meetings and confirm attendance with a signature on the “POC/IDG Review” forms to discuss the holistic care being provided to the patient. The DPCS stated the chaplain must provide update to the IDG members regarding Patient 3's understanding of the “spiritual aspect of what’s happening to them.”b. During a review of Patient 4’s “Personal Information,” the record indicated Patient 4’s SOC was on 3/11/2025, with a primary diagnosis of Alzheimer’s disease with late onset (progressive mental deterioration in adults 65 years or older, leading to a decline in memory, thinking, and other cognitive functions).During a review of Patient 4’s “Plan of Care/ Interdisciplinary Group (POC/IDG) Review,” dated 3/27/2025, the review indicated, “There are no reported psychosocial issues or interventions needed at this time. The Medical Social Worker (MSW) will continue to visit as scheduled...Initial evaluation within 5 days for psychosocial counseling and support to patient and family.” During a concurrent interview and record review, on 6/6/2025 at 12:40 PM, with the DPCS, Patient 4’s electronic health records was reviewed. The DPCS stated there was no documented evidence that Patient 4 had psychosocial assessment done by the MSW. The DPCS stated Patient 4’s “POC/IDG Review” notes, dated 3/27/2025, 4/10/2025, 4/24/2025, and 5/22/2025 did not have a MSW signature. The DPCS stated it was important for the MSW to attend the IDG meetings and confirm attendance with a signature on the “POC/IDG Review” forms to discuss the holistic care being provided to the patient. The DPCS stated the MSW must help the patient with his/her non-physiological challenges and notify the IDG members regarding the patient’s challenges and overall well-being.c. During a review of patient 6’s "Personal Information," the record indicated Patient 6's SOC was on 12/18/2024, with a primary diagnosis of Acute ischemic heart disease (a group of conditions where there is sudden and significant decrease in blood flow to the heart muscle, often due to blockage in a coronary artery [the blood vessel that supplies oxygen rich blood to the heart muscle]).During a review of Patient 6’s Electronic Medical Record (EMR), Patient 6’s EMR indicated that the Medical Social Worker (MSW) did not complete or submit a psychosocial assessment since the SOC of 12/18/2024.During a review of Patient 6’s EMR, Patient 6’s EMR indicated that the Spiritual Counselor (SC) did not complete or submit a spiritual assessment since the patient’s SOC of 12/18/2024.During an interview on 6/5/2025 at 11:47am, with Medical Social Worker 1 (MSW1), MSW1 stated part of her duties as an MSW is to conduct the psychosocial assessment within 5 days of the patients SOC. MSW1 stated the importance of conducting a psychosocial assessment for every patient admitted is to see how the patient’s brain works, understand what is going on with them emotionally and what they need, listen to their concerns, assess family needs, and also provide the patient or family with community assistance ass needed like applications for programs. MSW1 stated a patient’s psychosocial assessment can be found in the EMR under the section history of assessments and stated if it is not there then it was not done. MSW 1 stated if a patient denies MSW services, it should be documented in the patient's EMR. During a concurrent interview and record review, on 6/6/2025 at 1:30pm with the Administrator/Director of Patient Care Services (DPCS), the DPCS stated Patient 6’s EMR did not have a documentation of spiritual and psychosocial assessment since SOC date of 12/18/2024. The DPCS stated the importance of conducting a spiritual and psychosocial assessments is to have a baseline of the patient and their family, of where they are at emotionally and spiritually, educate them on services that are available to them to help cope and provide them with community resources as needed. d. During a review of Patient 10’s “Personal Information,” the record indicated Patient 10's SOC was on 5/2/2025, with a primary diagnosis of acute ischemic heart disease (a sudden, severe reduction in blood flow to the heart muscle, leading to a lack of oxygen and nutrients), unspecified.During a review of Patient 10’s “Plan of Care/Interdisciplinary Group Review,” dated 5/2/2025, the review indicated the MSW to do, “Initial evaluation within 5 days for psychosocial counseling and support to patient and family.”During a concurrent interview and record review, on 6/6/2025 at 1:48 PM, with the DPCS, Patient 10’s electronic health records was reviewed. The DPCS stated Patient 10's psychosocial assessment was not completed by the assigned MSW. The DPCS stated it was important for the MSW to complete the patient’s psychosocial assessment and to address any issues or concerns regarding the holistic care to be provided to the patients. The DPCS stated the MSW must help the patient with his/her non-physiological challenges and notify the IDG members regarding the patient’s challenges to take care of the patient’s overall well-being. e. During a review of Patient 14’s "Personal Information," the record indicated Patient 14's SOC was on 5/25/2024 and an end of care (EOC) date of 5/31/2025, with primary diagnosis of multiple myeloma (a type of blood cancer that affects plasma cells, which are white blood cells that produce antibodies to fight infections) in relapse (a return to a previous condition after a period of improvement).  During a review of Patient 14’s “POC/IDG Review,” dated 5/25/2025, the review indicated “Spiritual Counselor (SC) would do initial assessment to provide spiritual support to patient and family. May conduct telehealth visits if it is feasible and appropriate to do so.”    During a concurrent interview and record review, on 6/6/2025 at 1:51 PM, with the DPCS, Patient 14’s electronic health record was reviewed. The DPCS stated there was no initial spiritual assessment done by the Chaplain. The DPCS stated the chaplain must update the IDG members regarding the patient’s understanding of the “spiritual aspect of what’s happening to them.”During a review of the HA’s policy and procedures (P&P), titled “Comprehensive Assessment,” undated, the P&P indicated the following:1.     The comprehensive patient assessment must be performed by the IDG no later than 5 calendar days after the election of hospice care in consultation with the attending physician.2.     All baseline data and other relevant information must be documented in the patient’s clinical record including, but is not limited to, the following:a.     Patient and family/caregiver support systems and the care the family/caregiver is available, capable, and willing to provide, including applicable strengths of patient, physical, psychosocial, and/or spiritual resources available.b.    As assessment of the patient’s and family/caregiver’s spiritual orientation, including, as appropriate, any involvement in a religious group such as a church or synagogue or a support group and spiritual concerns or needs such as despair, suffering, guilt, etc. During a review of the HA’s P&P titled “Spiritual Care Counseling Services,” undated, the P&P indicated the following:1.     The Chaplain must be a member of the IDG and must participate in the development, implementation, and revision of the plan of care. 2.     The Chaplain must contribute to the comprehensive assessment and ongoing updates to the comprehensive assessment based on the needs of the patient and family. 3.     The Chaplain must develop an individualized spiritual/pastoral plan of care, which would demonstrate an effort to work closely with the local clergy as desired by the patient, and provision of spiritual support as defined and requested by the patient and family/caregiver.4.     Spiritual care assessments and counseling must be documented in the patient’s clinical record as part of the comprehensive assessment and in interdisciplinary visit notes, as well as the plan of care.5.     The Chaplain must attend the IDG meetings and must work in a team approach with members of the IDG and other qualified professionals to evaluate patient and family/caregiver response and resolution of ethical issues. During a review of the HA’s P&P titled “Psychosocial Services,” undated, P&P indicated the following:1.     The HA must provide psychosocial services by qualified social workers under the direction of a physician and in accordance with the plan of care. 2.     Psychosocial services must include a) assessing emotional factors related to terminal illness, b) patient and family/caregiver counseling around issues of death, dying, and grief, c) team and personnel support by assisting the physician and other IDG members in recognizing and understanding the social/mental stress and/or disorder that exacerbates symptoms related to the terminal illness, and d) financial and community resource referrals.3.     The social worker must be a member of the IDG and must participate in the development, implementation, and revision of the plan of care. 4.     The psychosocial assessments and interventions must be documented in the patient’s clinical record as part of the comprehensive assessment and in interdisciplinary visit notes, as well as the plan of care.

Based on observation, interview, and record review, the Hospice Agency (HA, agency who provides specialized care and support for people with a serious illness who are nearing the end of life) failed to review all the medications and update the medication profile with the currently used medications for two of nineteen sampled patients (Patient 10 and Patient 15).  This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. --- Findings: a. During a review of Patient 10’s clinical record titled “Personal Information undated,” the Personal Information indicated a start of care (SOC) date of 5/2/2025, with a primary diagnosis of acute ischemic heart disease (a sudden, severe reduction in blood flow to the heart muscle, leading to a lack of oxygen and nutrients), unspecified.  During a review of Patient 10’s clinical record titled “Plan of Care/Interdisciplinary Group Review (POC/IDG Review, a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors),” dated 5/19/2025 indicated, an order for Skilled Nurse visit frequency of one time a week and one as needed (PRN) visit to assess changes of condition, shortness of breath, promote comfort, and pain and symptom management.    During a concurrent home visit observation, interview, and record review, on 6/4/2025 at 10:35 a.m., to Patient 10’s residence, with Registered Nurse (RN 1), Patient 10 was observed resting comfortably on her chair. Patient 10 is alert, awake and oriented to her name, time, place and events.  RN1 reviewed the medications Patient 10 was currently taking, using the patient’s record titled, “Current Treatment/Medication/DME (Durable Medical Equipment) List” printed on 6/4/2025.  The following medications were not listed in Patient 10’s current medication list, but the medications were available at Patient 10’s home:-         RN1 stated “Magnesium 500 milligram (mg, unit of weight)” (over the counter, non-prescribed supplement medication) was in Patient 10’s medications supply.-         RN1 stated “Vitamin B complex” (OTC -over the counter, non-prescribed supplement medication) was in Patient 10’s medications supply.-         RN1 stated “Vitamin A 2400 microgram (mcg, unit of weight)” (over the counter, non-prescribed supplement medication) was in Patient 10’s medications supply.-         RN1 stated “Biotin 500 mcg” (over the counter, non-prescribed supplement medication) was in Patient 10’s medications supply.-         RN1 stated “Turmeric 500 mg” (over the counter, non-prescribed supplement medication) was in Patient 10’s medications supply.-         RN1 stated “Vitamin D3 500 mcg” (over the counter, non-prescribed supplement medication) was in Patient 10’s medications supply.-         RN1 stated “Iron 65 mg” (over the counter, non-prescribed supplement medication) was in Patient 10’s medications supply. During interview at 10:50 a.m. with RN1, RN1 stated the medication review and reconciliation was supposed to be done on every visit.  RN1 stated that if there is a change of medication, the patient’s medication list should be updated.  RN stated that she did not see the OTC medications during her previous home visit to Patient 10 from last week. RN 1 stated that Patient 10 did not tell her about the OTC medications from her last visit. RN1 stated that patient’s medication reconciliation consists of counting all the remaining medication supply, checking for the expiration dates, inquiring from patient of any new medications he or she is taking. RN1 stated that the importance of the medication review was to know what medications Patient 10 was receiving and to know if what medications were effective. RN1 stated that patient and/or patient’s caregivers need to be asked if there were any over the counter (OTC) medications or medications that need to be added to active medication lists. RN1 stated that patient’s medications need to be checked to ensure that all is current includes prescribed and over the counter medications. RN1 stated that new medications and OTC medications need to be brought to doctor’s attention and if approved, then the medications will be entered to patient’s current medication list. During interview at 11:00 a.m.  with Patient 10, Patient 10 stated that she does not think that OTC vitamins are medications since she does not need a prescription for it. Patient 10 stated that she takes the OTC medications as directed in each bottle’s instructions. During a concurrent interview and record review on 6/6/2025 at 1:31 p.m. with the Administrator/Director of Patient Care Services (DPCS), Patient 10’s electronic health records were reviewed. The DPCS confirmed and stated that Patient 10’s current medication list did not include the OTC medications identified as available during a joint home visit on 6/4/2025 at Patient 10’s residence with RN1. The DPCS stated that visiting nurses should have conducted medication reconciliation on every visit, to ensure that patient had all the ordered medications and OTC medications were accounted for. b. During a review of patient 15’s “admission record” it indicated a start of care (SOC) date of 11-16-23 with a terminal diagnosis of Alzheimer’s Disease is a progressive disease that alters one’s ability to think and remember things clearly, it progressively gets worse over time.  During a review of patient 15’s “plan of care summary” dated 6/6/25 it indicated the frequency of visits of skilled nursing (SN) is 1 per week, and Health Aide visits of (HA) 1 per week. During a review of patient 15’s “current treatment/medication/DME list” dated 6-4-25 indicated all current medications patient 15 was currently taking. During a home visit on  6-4-25 it was discovered that patient 15 had additional medication in the home and not on the current medication list. The medications found in home and not on med list were: 1)       Carbidopa- levodopa 10-100 tab po 3xday2)       Milk of magnesia saline laxative3)       Geri- Lantis antacid Medication listed on current med list but not found in home1)       Dulcolax 1200mg/15ml liquid, take 30-60ml daily as needed for constipation.During an interview with LVN3 conducted on 6-4-25 at 2:15pm, She indicated the medication profile for patient 15 was not accurate and did not completely match the current MAR. She stated medication reconciliation should be completed with each home visit to ensure the patient is receiving exactly what the physician ordered. She stated she will update MAR to ensure it completely matches what MD ordered.During an interview on 6-5-25 at 1:30pm with the Administrator/Director of Patient Care Services (DPCS), the DPCS indicated that medication reconciliation should be completed with each home visit to ensure patient is receiving what physician ordered. Informed the DPCS that the MAR for Patient 10 was not completely updated on home visit. The DPCS stated they will recheck physician orders and pharmacy to ensure the patient is receiving exactly what is ordered. She further stated that all nursing staff will be counseled to evaluate if med recons are happening with each visit.      During a review of the HA’s Policy and Procedure (P&P) titled Medication profile, undated, indicated 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.

Based on interview and record review the Hospice Agency (HA) failed to ensure an initial bereavement (is the physical and mental impact of losing a loved one) assessment was completed for three of nineteen sampled patients (Patient 3, Patient 6, and Patient 14).This failure had the potential to result in placing the patient and family/caregiver at risk of spiritual, emotional distress and to impact a family members' abilities to cope with the patients' death. --- Findings: A.    During a review of Patient 3’s medical form, titled “Personal Information,” the “Personal Information” indicated Patient 3’s Start of Care SOC date of 4/23/2025 with a primary diagnosis of prostate cancer (cancer that develops in the small gland in the male reproductive system). During a review of Patient 3’s medical form, titled “POC/IDG Review,” dated 4/23/2025, the “POC/IDG Review” indicated the “Bereavement Coordinator to assess and evaluate bereavement and grieving risk factor within 5 days of admission.”During a concurrent interview and record review on 6/6/2025 at 1:01 PM with the Administrator/DPCS, Patient 3’s electronic health records were reviewed. The Administrator/DPCS stated there was no initial bereavement assessment done. B. During a review of patient 6’s clinical record titled Personal Information undated, indicated a Start of Care (SOC) date of 12/18/2024, with a primary diagnosis of Acute ischemic heart disease (a group of conditions where there is sudden and significant decrease in blood flow to the heart muscle, often due to blockage in a coronary artery [the blood vessel that supplies oxygen rich blood to the heart muscle]).During a review of Patient 6’s clinical record titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 5/22/2025, indicated an order for Skilled Nurse (SN) visit frequency of one time per week to assess changes in condition, shortness of breath, pain and symptom management.During a review of Patient 6’s Electronic Medical Record (EMR), Patient 6’s EMR, under section history of bereavement assessment, indicated there was no documented evidence of an initial bereavement assessment completed since Patient 6’s SOC of 12/18/2024.During an interview on 6/6/2025 at 1pm with the Administrator/Director of Patient Care Services (DPCS), the DPCS stated the HA chaplain/ Spiritual Counselor will conduct and documents the initial bereavement assessment. The DPCS stated the initial bereavement assessment provides an idea of where the patient is on their disease process and spiritually how they are dealing with it, especially if its progressing.During a concurrent interview and record review on 6/6/2025 at 1:30pm with the Administrator/Director of Patient Care Services (DPCS), Patient 6’s EMR was reviewed. Patient 6’s EMR, under the section history of bereavement assessment, indicated there was no documented evidence of an initial bereavement assessment completed and submitted since Patient 6’s SOC of 12/18/2024. The DPCS stated and confirmed that Patient 6’s EMR did not have a completed initial bereavement assessment. The DCPS stated the initial bereavement assessment is to be completed and submitted within 5 days of the patients SOC. The DPCS further stated if the assessment is not in the patient’s EMR then it means it was not conducted. C. During a review of Patient 14’s clinical record titled Personal Information undated, the Personal Information indicated a SOC date of 5/25/2024 and an end of care (EOC) date of 5/31/2025, with primary diagnosis of multiple myeloma (a type of blood cancer that affects plasma cells, which are white blood cells that produce antibodies to fight infections) in relapse (a return to a previous condition after a period of improvement).  During a review of Patient 14’s medical form titled POC/IDG Review, dated 5/25/2025, the POC/IDG Review indicated the “Bereavement Coordinator to assess and evaluate bereavement and grieving risk factor within 5 days of admission.”  During a concurrent interview and record review on 6/6/2025 at 1:58 PM with the Administrator/DPCS, Patient 14’s electronic health records were reviewed. The Administrator/DPCS stated there was no initial bereavement assessment done. The Administrator/DPCS stated that it is important for the Bereavement Coordinator to conduct an assessment upon patient’s admission to hospice to address possible patient’s/patient’s family members’ bereavement/grief issues and to implement the identified concerns as needed.  During a review of the HA’s undated policy and procedures (P&P 1), titled “Bereavement Services,” P&P 1 indicated the following:1.     The purpose of the bereavement services was to facilitate a normal grieving process and to identify and appropriately refer those persons who might be experiencing pathological grief reactions that might interfere with the eventual resolution and integration of their losses.2.     A bereavement risk assessment must be completed by the hospice social worker at the time of admission to hospice, and the information gathered must be incorporated into the plan of care and considered in the bereavement plan of care.3.     Depending on the patient and family/caregiver needs identified in the bereavement assessment, bereavement counselors might need to contact and/or visit the patient and family/caregiver prior to the patient’s death to provide supportive counseling. During a review of the HA’s undated policy and procedures (P&P 2), titled “Comprehensive Assessment,” P&P 2 indicated the following:1.     The comprehensive patient assessment must be performed by the IDG no later than 5 calendar days after the election of hospice care in consultation with the attending physician.2.     All baseline data and other relevant information must be documented in the patient’s clinical record including, but is not limited to, a bereavement assessment of the needs of the patient’s family and other individuals focusing on a) nature of the relationship to the patient, b) circumstances surrounding the illness/prognosis, c) behaviors prior to and after the illness/prognosis, d) survivor needs (social, spiritual, and cultural) that may impact coping skills, and e) potential for pathological grief reactions.

Based on interview and record review the Hospice Agency (HA) failed to conduct an accurate and updated comprehensive assessment that reflected the patient’s current health status in relation to terminal diagnosis for two of nineteen sampled patients (Patient 2, and Patient 11).This deficient practice had the potential to result inaccurate assessment to appropriately address the patient’s individualized needs. --- Findings: A.    During a review of HA’s medical form, titled “Personal Information,” the “Personal Information” indicated Patient 2’s Start of Care (SOC) on 1/3/2025 and End of Care (EOC) on 4/16/2025 with a primary diagnosis of malignant neoplasm of mandible (jaw/jawbone cancer). During a review of Patient 2’s History and Physical Examination (H&P), dated 8/24/2024, the H&P indicated Patient 2 had a “history of mandibular squamous carcinoma (most common type of oral cancer) who came to the hospital with failure to thrive (FTT, syndrome of progressive decline in physical and/or mental function in adults).” The H&P indicated Patient 2 had “previous tooth extractions which have shown atypical squamous cell hyperplasia (ASCH, abnormal growth of flat, scale-like cells that make up the outer layer of the skin and other tissues with atypical characteristics).” The H&P indicated Patient 2 had been “taking Tylenol (analgesic medication to relieve minor to moderate aches and pain) and hydrocodone (opioid medication to treat moderate to severe pain) without significant relief.” The H&P indicated Patient 2’s physical examination of the Head, Eyes, Ears, Nose, and Throat (HEENT) was “notable for teeth removed from lower jaw with poor healing.” During a review of Patient 2’s Comprehensive Nursing Assessment, dated 1/3/2025, the Comprehensive Nursing Assessment indicated Patient 2 was awake, alert, and oriented to time, place, and self. The Comprehensive Nursing Assessment indicated Patient 2 was “restless,” “depressed,” and experiencing “fatigue.” The Comprehensive Nursing Assessment indicated Patient 2 was “uncomfortable because of pain” and had a blood pressure of 172/98 (abnormally high) and a heart rate of 81 beats per minute. The Comprehensive Nursing Assessment indicated Patient 2’s oral cavity was “normal.” The Comprehensive Nursing Assessment indicated Patient 2 had 6/10 lower back pain and Patient 2 was instructed by Registered Nurse 1 (RN 1) to take Norco (pain medication combination of acetaminophen and opioid hydrocodone)  5 milligrams-325 milligrams tablet. The Comprehensive Nursing Assessment indicated RN 1 encouraged Patient 2’s caregiver to “gently massage patient’s affected area to reduce discomfort.” The Comprehensive Nursing Assessment indicated RN 1 educated Patient 2 non-pharmacological techniques, which would “help to make her condition better, such as rest, relaxation, etc.” During a review of Patient 2’s POC/IDG Review, dated 1/3/2025, the POC/IDG review indicated the following:1.     Patient 2 was prescribed acetaminophen 160 milligrams orally every 8 hours for pain, aspirin 81 milligrams chewable tablet orally daily for pain, and Norco 5 milligram-325 milligram tablet orally every 6 hours as needed for pain.2.     Skilled Nurse to report to the physician for pain greater than 5/10 and not relieved with rest and current prescription pain medications. The plan was to provide symptoms management, pain control and comfort measures.3.     Plan of care (POC) for “generalized body pain” indicated the goal to “bring down pain to less than 3 or within the patient’s tolerable level (2/10) for comfort within 48 hours of admission.” POC indicated interventions included a) Instructing the family/PCG to give pain medications when pain level is greater than 2 or above, b) instruct on non-pharmacological methods of pain and symptom relief of repositioning, music therapy and/or calm, quiet environment, and c) administering acetaminophen and Norco tablet for pain as prescribed. During a review of Patient 2’s Visit Note, dated 1/10/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s VNs on 2/3/2025 “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). The Visit Note did not indicate any swelling to the jaw area. During a review of Patient 2’s Visit Note, dated 1/17/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s VNs on 2/3/2025 “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). The Visit Note did not indicate any swelling to the jaw area. During a review of Patient 2’s Visit Note, dated 1/24/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s VNs on 2/3/2025 “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). The Visit Note did not indicate any swelling to the jaw area. During a review of Patient 2’s Visit Note, dated 1/31/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s VNs on 2/3/2025 “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). The Visit Note did not indicate any swelling to the jaw area. During a review of Patient 2’s Visit Note, dated 2/7/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s VNs on 3/3/2025 “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). The Visit Note did not indicate any swelling to the jaw area. During a review of Patient 2’s Visit Note, dated 2/14/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s VNs on 3/3/2025 “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). The Visit Note did not indicate any swelling to the jaw area. During a review of Patient 2’s Visit Note, dated 2/21/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s VNs on 3/3/2025 “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). The Visit Note did not indicate any swelling to the jaw area. During a review of Patient 2’s Visit Note, dated 2/28/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s VNs on 3/3/2025 “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). The Visit Note did not indicate any swelling to the jaw area. During a review of Patient 2’s Visit Note, dated 3/7/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s VNs on 4/1/2025 “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). The Visit Note did not indicate any swelling to the jaw area. During a review of Patient 2’s Visit Note, dated 3/14/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s VNs on 4/1/2025 “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 5/10 pain and “pain patch is not helping.” The Visit Note did not indicate any swelling to the jaw area. During a review of Patient 2’s Visit Note, dated 3/28/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s VNs on 4/1/2025 “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 5/10 pain on multiple sites. The Visit Note did not indicate any swelling to the jaw area. During a review of Patient 2’s Discharge Summary, dated 4/16/2025, the Discharge Summary indicated “Patient/family have elected to revoke hospice services at this time to seek further aggressive treatment.” During an interview on 6/5/2025 at 12:12 PM, Patient 2’s Family Member (FM 1) stated HA licensed nurses did not properly assess Patient 2’s jaw area swelling and pain level while Patient 2 was under their care. FM 1 stated Patient 2 developed multiple abscesses in the lower jaw area, which required hospitalization. FM 1 stated Patient 2 was “in so much pain, but nobody seemed to care and there was no pain relief.” FM 1 stated Patient 2 “couldn’t eat because of the pain.” During an interview on 6/5/2025 at 1:08 PM, Licensed Vocational Nurse 1 (LVN 1) stated Patient 2 always had pain level of 8/10 or 9/10 during the nursing home visits. LVN 1 stated Patient 2 had swelling to the left jaw upon admission and the swelling got “a little bigger” after a few weeks. LVN 1 stated she documented her assessments on Patient 2’s electronic health records. LVN 1 stated she did not why the Visit Notes did not reflect the pain level and the swelling to the left jaw. During a concurrent interview and record review on 6/6/2025 at 12:08 PM with the Administrator/Director of Patient Care Services (DPCS), Patient 2’s Visit Notes were reviewed. The Administrator/DPCS stated there was no documented evidence of Patient 2’s pain level of 8/10 and 9/10 and left jaw swelling. The Administrator/DPCS stated the pain level must be assessed by the licensed nurse at every home visit. The Administrator/DPCS stated if the patient has pain, the licensed nurse can administer the pain medication and observe the patient for about 30 minutes to an hour to reassess the pain level. The Administrator/DPCS stated if the pain is still uncontrolled, the licensed nurse must notify the physician if the patient would need an order for a breakthrough pain medication. The Administrator/DPCS stated it was important to take and document the patient’s vital signs at every home visit, because the HA staff need to “see the direction where the patient is going (improve or decline).” During a concurrent interview and record review on 6/6/2025 at 3:41 PM, the Administrator/DPCS stated Patient 2 was “adamant that pain pills were not going to help her.” The Administrator/DPCS stated the Visit Note, dated 3/25/2025, indicated Patient 2 “had already taken her pain medication and pain patch was applied but she is still complaining of continuous pain.” The Administrator/DPCS stated Patient 2 had mild swelling to the jaw area.   b. During a review of Patient 11’s clinical record titled Personal Information undated, the Personal Information indicated a start of care (SOC) date of 11/24/2024, with a primary diagnosis of chronic obstructive pulmonary disease (a progressive lung disease that causes long-term inflammation and damage to the airways and lungs), unspecified. During a concurrent interview and record review on 6/6/2025 at 1:10 p.m., with the Administrator/Director of Patient Care Services (DPCS), Patient 11’s electronic medical record (EMR, a digital version of a patient's medical chart, containing all the information found in a traditional paper chart, but stored electronically on a computer) indicated the following:-         Patient 11’s EMR titled, “Visit Note RN (Registered Nurse)” dated 4/20/2025, Patient 11’s Visit Note RN indicated in the “Respiratory” section, documented as Dyspnea (difficulty in breathing) – easy breathing, Abnormal Lung Sound – None, Cough – Never, Other Symptom – None.-         Patient 11’s EMR titled, “Visit Note LVN” dated 4/21/2025, Patient 11’s Visit Note LVN indicated in the “Respiratory” section, documented as Dyspnea – easy breathing, Abnormal Lung Sound – None, Cough – Never, Other Symptom – None.-         Patient 11’s EMR titled, “Visit Note LVN” dated 4/28/2025, Patient 11’s Visit Note LVN indicated in the “Respiratory” section, documented as Dyspnea – easy breathing, Abnormal Lung Sound – None, Cough – Never, Other Symptom – None.-         Patient 11’s EMR titled, “Visit Note LVN” dated 4/28/2025, Patient 11’s Visit Note LVN indicated in the “Respiratory” section, documented as Dyspnea – easy breathing, Abnormal Lung Sound – None, Cough – Never, Other Symptom – None.-         Patient 11’s EMR titled, “Visit Note LVN” dated 5/5/2025, Patient 11’s Visit Note LVN indicated in the “Respiratory” section, documented as Dyspnea – easy breathing, Abnormal Lung Sound – None, Cough – Never, Other Symptom – None.-         Patient 11’s EMR titled, “Visit Note LVN” dated 5/12/2025, Patient 11’s Visit Note LVN indicated in the “Respiratory” section, documented as Dyspnea – easy breathing, Abnormal Lung Sound – None, Cough – Never, Other Symptom – None.-         Patient 11’s EMR titled, “Visit Note LVN” dated 5/26/2025, Patient 11’s Visit Note LVN indicated in the “Respiratory” section, documented as Dyspnea – easy breathing, Abnormal Lung Sound – None, Cough – Never, Other Symptom – None. The DPCS stated that Patient 11’s primary diagnosis is COPD and the respiratory assessments for the reviewed nursing visits did not reflect Patient 11’s current health status. The DPCS stated that if Patient 11’s overall condition is improving, then it should have been discussed with the Interdisciplinary Group Team (IDG (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) members and communicated with the medical doctor as well. The DPCS stated that it is important to determine the patient's current health status to provide the necessary care and treatments for the patient. During a telephone interview on 6/5/2025 at 12:59 p.m. with Licensed Vocational Nurse 2(LVN2), LVN 2 confirmed and stated that he visited Patient 11 on the dates of 4/21/2025, 4/28/2025,5/5/2025, 5/12/2025, and 5/26/2025. LVN2 stated that he documented and submitted his assessments on each visit via electronically on his computer access. LVN 2 stated that Patient 11 has a COPD, stated her overall condition is declining, and her baseline respiratory status is not normal, has a diminished lung sound, has shortness of breath which reflect her current health status. LVN 2 stated that he should have documented his findings and assessments properly in Patient 11’s respiratory status. LVN 2 stated that it was his mistake of assessments and documentations.      During a review of the HA’s undated Policy and Procedure (P&P1), titled Ongoing Assessments, undated,  indicated the following:1.     During each home visit, the Case Manager or other discipline must evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment.2.     The nurse must assess the patient on each visit for a) pain, including the origin, location, duration, severity, and relief measures, b) factors that alleviate or exacerbate physical symptoms, c) current treatment related to the identified symptoms and the patient’s response, d) vital signs appropriate to the patient’s condition, e) skin integrity, f) progress towards hospice goals and patient needs and problems, and g) compliance with treatments and medication regimen.3.     Ongoing comprehensive assessments should focus on a) patient’s response to care, b) changes in patient’s condition, level of deterioration, c) changes in patient diagnoses/prognosis, and d) changes in the patient’s care environment or support systems.4.     Based on the assessments, the plan of care—including problems, needs, goals, and outcomes—must be reviewed and update by the IDG members responsible for the case.

Based on observation, interview, and record review, the Hospice Agency (HA- agency who provides specialized care and support for people with a serious illness who are nearing the end of life) failed to meet the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for IDG, Care planning, and Coordination of Services. --- 1. The HA failed to ensure that the Care plan for two of 19 sampled patients (Patient 2 and Patien10) was individualized based on their current, personal needs.a. No care plan for Patient 2’s jaw swellingb. No care plan for Patient 10’s bleeding precautions This failure had the potential to result in a lack or delay in delivery of necessary care and services for Patient 2 and Patient 10. (refer to L545) 2.The HA failed to individualize the care plan for pain for one of 19 sampled patients (Patient2) to reflect Patient 2’s history of no significant relief from acetaminophen (analgesic to relieve mild to moderate pain) and hydrocodone (opioid medication to treat moderate to severe pain).This failure resulted in Patient 2 with no pain relief and not being able to eat due to ineffective pain management. (refer to L546)  3. The HA failed to ensure the IDG (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) members met to review the IDG/POC for eight of nineteen sampled patients (Patient 1, Patient 3, Patient 4, Patient 5, Patient 8, Patient 12, Patient 15, and Patient 18).This failure had the potential to result in the decline of health of Patient 1, Patient 3, Patient 4, Patient 5, Patient 8, Patient 12, Patient 15, and Patient 18 due to not receiving care in accordance with their personal needs due to lack of coordination of care.  (refer to L552)  4. The HA failed to follow the written Plan of Care (POC [documents the process of identifying a patient's needs and facilitating complete care and ensures collaboration among nurses, patients, and other healthcare providers]) for one of nineteen sample patients (Patient 15).a.     Missed Skilled Nurses (SN) visit for Patient 15b.    Missed supervisory RN visits for Patient 15This failure had the potential to result in Patient 15 not receive the individualized and needed services and treatments as prescribed by the physician that could have affected their overall health and well-being. (refer to L555) The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure provision of the highest quality care and services to all certified hospice patients.

Based on interview and record review, the hospice agency (HA) failed to ensure that the care plan for two of 19 patients (Patient 2 & Patient 10) was individualized based on their current, personal needs.a.     The HA did not develop an individualized care plan for Patient 2’s jaw swelling.b.    The HA did not develop an individualized care plan for Patient 10’s bleeding precautions. These failures had the potential to result in lack of delay in the delivery of the necessary care and services for the patients. --- Findings:A.    During a review of HA’s medical form, titled “Personal Information,” the “Personal Information” indicated Patient 2’s Start of Care (SOC) on 1/3/2025 and End of Care (EOC) on 4/16/2025 with a primary diagnosis of malignant neoplasm of mandible (jaw/jawbone cancer).During a review of Patient 2’s History and Physical Examination (H&P), dated 8/24/2024, the H&P indicated Patient 2 had a “history of mandibular squamous carcinoma (most common type of oral cancer) who came to the hospital with failure to thrive (FTT, syndrome of progressive decline in physical and/or mental function in adults).” The H&P indicated Patient 2 had “previous tooth extractions which have shown atypical squamous cell hyperplasia (ASCH, abnormal growth of flat, scale-like cells that make up the outer layer of the skin and other tissues with atypical characteristics).” The H&P indicated Patient 2’s physical examination of the Head, Eyes, Ears, Nose, and Throat (HEENT) was “notable for teeth removed from lower jaw with poor healing.”During a review of Patient 2’s Comprehensive Nursing Assessment, dated 1/3/2025, the Comprehensive Nursing Assessment indicated Patient 2 was awake, alert, and oriented to time, place, and self. The Comprehensive Nursing Assessment indicated Patient 2 was “restless,” “depressed,” and experiencing “fatigue.” The Comprehensive Nursing Assessment indicated Patient 2 was “uncomfortable because of pain” and had a blood pressure of 172/98 (abnormally high) and a heart rate of 81 beats per minute. The Comprehensive Nursing Assessment indicated Patient 2’s oral cavity was “normal.” During a review of Patient 2’s Visit Notes, dated 1/10/2025, 1/17/2025, 1/24/2025, 1/31/2025, 2/7/2025, 2/14/2025, 2/21/2025, 2/28/2025, 3/7/2025, 3/14/2025, 3/28/2025, the Visit Notes (VNs) indicated LVN 1 conducted the nursing home visits, but the HA Owner electronically signed Patient 2’s VNs “to close note on behalf of staff assigned.” The Visit Note did not indicate any swelling to the jaw area.During a review of Patient 2’s Discharge Summary, dated 4/16/2025, the Discharge Summary indicated “Patient/family have elected to revoke hospice services at this time to seek further aggressive treatment.”During an interview on 6/5/2025 at 12:12 PM, Patient 2’s Family Member (FM 1) stated HA licensed nurses did not properly assess Patient 2’s jaw area swelling and pain level while Patient 2 was under their care. FM 1 stated Patient 2 developed multiple abscesses in the lower jaw area, which required hospitalization. FM 1 stated Patient 2 was “in so much pain, but nobody seemed to care and there was no pain relief.” FM 1 stated Patient 2 “couldn’t eat because of the pain.”During an interview on 6/5/2025 at 1:08 PM, Licensed Vocational Nurse 1 (LVN 1) stated Patient 2 always had pain level of 8/10 or 9/10 during the nursing home visits. LVN 1 stated Patient 2 had swelling to the left jaw upon admission and the swelling got “a little bigger” after a few weeks. LVN 1 stated she documented her assessments on Patient 2’s electronic health records. LVN 1 stated she did not why the Visit Notes did not reflect the pain level and the swelling to the left jaw.During a concurrent interview and record review on 6/6/2025 at 12:08 PM with the Administrator/Director of Patient Care Services (DPCS), Patient 2’s Visit Notes were reviewed. The Administrator/DPCS stated there was no documented evidence of Patient 2’s pain level of 8/10 and 9/10 and left jaw swelling. During a concurrent interview and record review on 6/6/2025 at 3:41 PM, the Administrator/DPCS stated Patient 2 was “adamant that pain pills were not going to help her.” The Administrator/DPCS stated her Visit Note, dated 3/25/2025, indicated Patient 2 “had already taken her pain medication and pain patch was applied but she is still complaining of continuous pain.” The Administrator/DPCS stated Patient 2 had mild swelling to the jaw area. The Administrator/DPCS stated there was no care plan developed and implemented for Patient 2’s jaw swelling.  b. During a review of Patient 10’s clinical record titled “Personal Information undated,” the Personal Information indicated a start of care (SOC) date of 5/2/2025, with a primary diagnosis of acute ischemic heart disease (a sudden, severe reduction in blood flow to the heart muscle, leading to a lack of oxygen and nutrients), unspecified.  During a review of Patient 10’s clinical record “Current Treatment/Medication/DME (Durable Medical Equipment; any medical equipment used in the home to aid in a better quality of living)” indicated listed medication which includes: -         Anagrelide Hydrochloride1 milligram (mg, unit of weight) capsule, one capsule, oral (by mouth), every 12 hours a day, Blood Thinner (also known as anticoagulants, are medications that prevent blood clots from forming or growing larger).During a review of Patient 10’s clinical record titled “Plan of Care/Interdisciplinary Group Review (POC/IDG Review, a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors),” dated 5/2/2025 and  5/19/2025, did not include a care plan for bleeding precautions while on anti-coagulant medication.During a concurrent interview and record review on 6/6/2025 at 1:41 p.m. with the Administrator/Director of Patient Care Services (DPCS), Patient 10’s electronic health records were reviewed. The DPCS confirmed and stated that Patient 10’s “POC (Plan of Care) Summary, dated as of 6/4/2025 and Patient 10’s POC/IDG Review dated 5/2/2025 and 5/19/2025, the DPCS confirmed and stated that Patient 10’s POC Summary and POC/IDG Review did not include a care plan for bleeding precautions while on anti-coagulant medication. DPCS stated that a care plan should have been formulated for Patient 10 while in use of anticoagulant medications. DPCS stated that care plan must address potential problems and for the nursing team to be aware of the goals and interventions and current health status of patient. DPCS stated that patient teaching must be done at the start of the care and at random, stated that it needs to be documented and needs to provide written education materials.  During a review of the HA’s undated policy and procedures (P&P 1), titled “The Plan of Care,” P&P 1 indicated the following:1.     A written individualized patient and family/caregiver plan of care must be initiated at the start of care, established, and maintained for each patient admitted to the hospice program.2.     The plan of care must be based on the initial, comprehensive, and ongoing comprehensive assessments performed by the members of the IDG and must be reviewed on a regular basis but no less than every 15 days.3.     The care plan must focus on identified problems, goals, and interventions.4.     The patient and family//caregiver must be encouraged to participate in the development of and continued updating of the care plan. 5.     The care plan must be provided to both the attending physician and the hospice Medical Director for approval of verbal orders and certification of the terminal illness signatures. The hospice Medical Director must review the patient’s history and physical, which was also provided, to be able to sign the certification of terminal illness section of the care plan.6.     Each patient must be monitored for his/her response to care/services provided against established patient goals and patient outcomes to evaluate progress towards goals.7.     Care decisions and services to be provided must be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments, and analysis of patient response to care against goals and outcomes.8.     Review of the care plan must be documented in the clinical record, and revision dates must be noted on the care plan.

Based on interviews and record review, the hospice agency (HA) failed to individualize the care plan for pain for one of 19 sampled patients (Patient2) to reflect Patient 2’s history of no significant relief from acetaminophen (analgesic to relieve mild to moderate pain) and hydrocodone (opioid medication to treat moderate to severe pain). This failure resulted in Patient 2 with no pain relief and not being able to eat due to ineffective pain management. --- Findings: During a review of HA’s medical form, titled “Personal Information,” the “Personal Information” indicated Patient 2’s Start of Care (SOC) on 1/3/2025 and End of Care (EOC) on 4/16/2025 with a primary diagnosis of malignant neoplasm of mandible (jaw/jawbone cancer). During a review of Patient 2’s History and Physical Examination (H&P), dated 8/24/2024, the H&P indicated Patient 2 had a “history of mandibular squamous carcinoma (most common type of oral cancer) who came to the hospital with failure to thrive (FTT, syndrome of progressive decline in physical and/or mental function in adults).” The H&P indicated Patient 2 had “previous tooth extractions which have shown atypical squamous cell hyperplasia (ASCH, abnormal growth of flat, scale-like cells that make up the outer layer of the skin and other tissues with atypical characteristics).” The H&P indicated Patient 2 had been “taking Tylenol (generic name acetaminophen, an analgesic medication to relieve minor to moderate aches and pain) and hydrocodone (opioid medication to treat moderate to severe pain) without significant relief.” The H&P indicated Patient 2’s physical examination of the Head, Eyes, Ears, Nose, and Throat (HEENT) was “notable for teeth removed from lower jaw with poor healing.” During a review of Patient 2’s Comprehensive Nursing Assessment, dated 1/3/2025, the Comprehensive Nursing Assessment indicated Patient 2 was awake, alert, and oriented to time, place, and self. The Comprehensive Nursing Assessment indicated Patient 2 was “restless,” “depressed,” and experiencing “fatigue.” The Comprehensive Nursing Assessment indicated Patient 2 was “uncomfortable because of pain” and had a blood pressure of 172/98 (abnormally high) and a heart rate of 81 beats per minute. The Comprehensive Nursing Assessment indicated Patient 2’s oral cavity was “normal.” The Comprehensive Nursing Assessment indicated Patient 2 had 6/10 lower back pain and Patient 2 was instructed by Registered Nurse 1 (RN 1) to take Norco (pain medication combination of acetaminophen and opioid hydrocodone)  5 milligrams-325 milligrams tablet. The Comprehensive Nursing Assessment indicated RN 1 encouraged Patient 2’s caregiver to “gently massage patient’s affected area to reduce discomfort.” The Comprehensive Nursing Assessment indicated RN 1 educated Patient 2 non-pharmacological techniques, which would “help to make her condition better, such as rest, relaxation, etc.” During a review of Patient 2’s POC/IDG Review, dated 1/3/2025, the POC/IDG review indicated the following:1.     Patient 2 was prescribed acetaminophen 160 milligrams orally every 8 hours for pain, aspirin 81 milligrams chewable tablet orally daily for pain, and Norco 5 milligram-325 milligram tablet orally every 6 hours as needed for pain. 2.     Skilled Nurse to report to the physician for pain greater than 5/10 and not relieved with rest and current prescription pain medications. The plan was to provide symptoms management, pain control and comfort measures.3.     Plan of care (POC) for “generalized body pain” indicated the goal to “bring down pain to less than 3 or within the patient’s tolerable level (2/10) for comfort within 48 hours of admission.” POC indicated interventions included a) Instructing the family/PCG to give pain medications when pain level is greater than 2 or above, b) instruct on non-pharmacological methods of pain and symptom relief of repositioning, music therapy and/or calm, quiet environment, and c) administering acetaminophen and Norco tablet for pain as prescribed. During a review of Patient 2’s Visit Notes, dated 1/10/2025, 1/17/2025, 1/24/2025, 1/31/2025, 2/7/2025, 2/14/2025, 2/21/2025, 2/28/2025, and 3/7/2025, the Visit Notes (VNs) indicated LVN 1 conducted the nursing home visits, but the HA Owner electronically signed Patient 2’s VNs “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). During a review of Patient 2’s Visit Note, dated 3/14/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s VNs on 4/1/2025 “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 5/10 pain and “pain patch is not helping.”  During a review of Patient 2’s Visit Note, dated 3/28/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s VNs on 4/1/2025 “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 5/10 pain on multiple sites.  During a review of Patient 2’s Discharge Summary, dated 4/16/2025, the Discharge Summary indicated “Patient/family have elected to revoke hospice services at this time to seek further aggressive treatment.” During an interview on 6/5/2025 at 12:12 PM, Patient 2’s Family Member (FM 1) stated HA licensed nurses did not properly assess Patient 2’s jaw area swelling and pain level while Patient 2 was under their care. FM 1 stated Patient 2 developed multiple abscesses in the lower jaw area, which required hospitalization. FM 1 stated Patient 2 was “in so much pain, but nobody seemed to care and there was no pain relief.” FM 1 stated Patient 2 “couldn’t eat because of the pain.” During an interview on 6/5/2025 at 1:08 PM, Licensed Vocational Nurse 1 (LVN 1) stated Patient 2 always had pain level of 8/10 or 9/10 during the nursing home visits. LVN 1 stated Patient 2 had swelling to the left jaw upon admission and the swelling got “a little bigger” after a few weeks. LVN 1 stated she documented her assessments on Patient 2’s electronic health records. LVN 1 stated she did not why the Visit Notes did not reflect the pain level and the swelling to the left jaw. During a concurrent interview and record review on 6/6/2025 at 12:08 PM with the Administrator/Director of Patient Care Services (DPCS), Patient 2’s Visit Notes were reviewed. The Administrator/DPCS stated there was no documented evidence of Patient 2’s pain level of 8/10 and 9/10 and left jaw swelling. The Administrator/DPCS stated the pain level must be assessed by the licensed nurse at every home visit. The Administrator/DPCS stated if the patient has pain, the licensed nurse can administer the pain medication and observe the patient for about 30 minutes to an hour to reassess the pain level. The Administrator/DPCS stated if the pain is still uncontrolled, the licensed nurse must notify the physician if the patient would need an order for a breakthrough pain medication. The Administrator/DPCS stated it was important to take and document the patient’s vital signs at every home visit, because the HA staff need to “see the direction where the patient is going (improve or decline).” During a concurrent interview and record review on 6/6/2025 at 3:41 PM, the Administrator/DPCS stated Patient 2 was “adamant that pain pills were not going to help her.” The Administrator/DPCS stated the Visit Note, dated 3/25/2025, indicated Patient 2 “had already taken her pain medication and pain patch was applied but she is still complaining of continuous pain.” The Administrator/DPCS stated Patient 2’s care plan for pain was not individualized to include the use of pain patch and to address issues with hydrocodone and acetaminophen not providing significant pain relief, opioids causing bowel problems, and Patient 2’s history of chronic marijuana use. During a review of the HA’s undated policy and procedures (P&P 1), titled “The Plan of Care,” P&P 1 indicated the following:1.     A written individualized patient and family/caregiver plan of care must be initiated at the start of care, established, and maintained for each patient admitted to the hospice program.2.     The plan of care must be based on the initial, comprehensive, and ongoing comprehensive assessments performed by the members of the IDG and must be reviewed on a regular basis but no less than every 15 days.3.     The care plan must focus on identified problems, goals, and interventions.4.     The patient and family//caregiver must be encouraged to participate in the development of and continued updating of the care plan. 5.     The care plan must be provided to both the attending physician and the hospice Medical Director for approval of verbal orders and certification of the terminal illness signatures. The hospice Medical Director must review the patient’s history and physical, which was also provided, to be able to sign the certification of terminal illness section of the care plan.6.     Each patient must be monitored for his/her response to care/services provided against established patient goals and patient outcomes to evaluate progress towards goals.7.     Care decisions and services to be provided must be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments, and analysis of patient response to care against goals and outcomes.8.     Review of the care plan must be documented in the clinical record, and revision dates must be noted on the care plan. During a review of the HA’s undated policy and procedures (P&P 2), titled “Pain Assessment,” P&P 2 indicated the following:1.     When pain is identified, a more comprehensive pain assessment must be completed when warranted by the patient’s condition. Pain assessments must be appropriate to the patient’s age and must be documented to facilitate regular reassessment and follow-up by clinicians.2.     During the initial assessment and on an ongoing basis, the patient must be asked a general screening question regarding current or recent pain as part of the baseline data. Clinicians must consider the patient’s personal, cultural, spiritual, and ethnic beliefs when assessing pain or discomfort.3.     When the patient or the clinician identifies pain, the following in-depth pain assessment information must be obtained whenever possible: a) pain intensity using a rating scale and the patient must be reassessed every visit for the existence and intensity of pain and the effectiveness of interventions to relieve pain; b) pain location, c) pain quality, patterns of radiation, and character, d) pain onset, duration, variations, and patterns; and e) alleviating and aggravating factors;  f) present pain management regimen and effectiveness; and g) pain management history, to include a medication history, presence of common barriers to reporting pain and using analgesics, past interventions and response, and manner of expressing pain.4.     Effects of pain, including impact on daily life, function, sleep, appetite, relationships with others, emotions, concentration, etc.5.     The patient/family’s pain goal and satisfaction with goal, including pain intensity and goals related to function, activities, and quality of life.6.     Physical exam or observation of the site of pain.7.     Secondary symptoms related to pain such as nausea, vomiting, respiratory distress, or nutritional compromise.

Based on interviews and record review, the hospice agency (HA) failed to ensure the IDG (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) members met to review the IDG/POC for  eight of nineteen sampled patients (Patient 1, Patient 3, Patient 4, Patient 5, Patient 8, Patient 12, Patient 15, and Patient 18). This failure had the potential to result in the decline of health of Patient 1, Patient 3, Patient 4, Patient 5, Patient 8, Patient 12, Patient 15 and Patient 18 due to not receiving care in accordance with their personal needs due to lack of coordination of care. --- Findings: a.     During a review of Patient 1’s medical form, titled “Personal Information,” the “Personal Information” indicated Patient 1’s Start of Care SOC date of 12/23/2024 with a primary diagnosis of colon cancer (cancer that develops in the large intestine). During a review of Patient 1’s medical form, titled “POC/IDG Review,” dated 12/23/2024, the “POC/IDG Review” indicated initial Chaplain visit for initial consultation was offered, and Patient 1 and/or Patient 1’s responsible party accepted the initial consultation and follow-up as needed. The “POC/IDG Review” indicated “Spiritual Counselor (SC) to do initial assessment to provide spiritual support to patient and family. May conduct telehealth visits if it is feasible and appropriate to do so.” During a concurrent interview and record review on 6/6/2025 at 12:57 PM with the Administrator/DPCS, Patient 1’s “POC/IDG Review” notes were reviewed. The Administrator/DPCS stated there were no Chaplain signatures on Patient 1’s “POC/IDG Review” notes, dated 2/17/2025, 2/3/2025, 1/20/2025, 1/6/2025, and 12/23/2024. The Administator/DPCS stated it was important for the Chaplain to attend the IDG meetings and confirm attendance with a signature on the “POC/IDG Review” forms to discuss the holistic care to be provided to the patients. The Administrator/DPCS stated the chaplain must be able to update the IDG members regarding the patient’s understanding of the “spiritual aspect of what’s happening to them.” b.    During a review of Patient 3’s medical form, titled “Personal Information,” the “Personal Information” indicated Patient 3’s Start of Care SOC date of 4/23/2025 with a primary diagnosis of prostate cancer (cancer that develops in the small gland in the male reproductive system). During a review of Patient 3’s medical form, titled “POC/IDG Review,” dated 4/23/2025, the “POC/IDG Review” indicated initial Chaplain visit for initial consultation was offered, and Patient 3 and/or Patient 3’s responsible party accepted the initial consultation and follow-up as needed. The “POC/IDG Review” indicated “Spiritual Counselor (SC) to do initial assessment to provide spiritual support to patient and family. May conduct telehealth visits if it is feasible and appropriate to do so.” During a concurrent interview and record review on 6/6/2025 at 1:01 PM with the Administrator/DPCS, Patient 3’s electronic health records were reviewed. The Administrator/DPCS stated there were no Chaplain signatures on Patient 3’s “POC/IDG Review” notes, dated 4/23/2025, 5/5/2025, and 5/19/2025. The Administrator/DPCS stated there was no initial spiritual assessment and initial bereavement assessment done by the Chaplain. The Administator/DPCS stated it was important for the Chaplain to attend the IDG meetings and confirm attendance with a signature on the “POC/IDG Review” forms to discuss the holistic care to be provided to the patients. The Administrator/DPCS stated the chaplain must be able to update the IDG members regarding the patient’s understanding of the “spiritual aspect of what’s happening to them.” c.     During a review of Patient 4’s medical form, titled “Personal Information,” the “Personal Information” indicated Patient 3’s Start of Care SOC date of 3/11/2025 with a primary diagnosis of Alzheimer’s disease with late onset (progressive mental deterioration in adults 65 years or older, leading to a decline in memory, thinking, and other cognitive functions). During a review of Patient 4’s medical form, titled “POC/IDG Review,” dated 3/27/2025, the “POC/IDG Review” indicated “The Chaplain will keep offering spiritual support to the patient and their family as necessary.” The “POC/IDG Review” indicated “There are no reported psychosocial issues or interventions needed at this time. The Medical Social Worker (MSW) will continue to visit as scheduled.” The “POC/IDG Review” indicated the MSW to do “Initial evaluation within 5 days for psychosocial counseling and support to patient and family” once a month visits and as needed for patient/patient caregiver needs/request.  During a concurrent interview and record review on 6/6/2025 at 12:40 PM with the Administrator/DPCS, Patient 4’s electronic health records were reviewed. The Administrator/DPCS stated there were no Chaplain and MSW signatures on Patient 4’s “POC/IDG Review” notes, dated 3/27/2025, 4/10/2025, 4/24/2025, and 5/22/2025. The Administrator/DPCS stated there was no psychosocial assessment done by the MSW. The Administrator/DPCS stated it was important for the Chaplain and MSW to attend the IDG meetings and confirm attendance with a signature on the “POC/IDG Review” forms to discuss the holistic care to be provided to the patients. The Administrator/DPCS stated the MSW must be able to help the patients with their non-physiological challenges and notify the IDG members regarding the patient’s challenges to take care of the patients’ overall well-being. d.    During a review of patient 5’s clinical record titled Personal Information undated, indicated a Start of Care (SOC) date of 2/11/2025, with a primary diagnosis of Hypertensive heart disease without heart failure (damage to the heart caused by high blood pressure).During a review of Patient 5’s clinical record titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 5/22/2025, indicated an order for skilled Nurse (SN) visit frequency of one time per week and one as needed (PRN) visit to assess changes in condition, shortness of breath, pain and symptom management.During a review of Patient 5’s clinical records titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 3/13/2025, 3/27/2025, 4/10/2025, 4/24/2025, 5/8/2025, and 5/22/2025, Patient 5’s records indicated there was no signature for the Chaplain/Spiritual Counselor (SC) under chaplain signature section.During an interview on 6/6/2025 at 12:57pm with the Administrator/Director of Patient Care Services (DPCS), the DPCS stated the IDG members that are to attend the meetings are Medical Social Worker (MSW), Chaplain/Spiritual Counselor (SC), the Medical Director (MD), and the nurses who provide care to the patient. The DPCS stated the IDG meetings are held in person and mostly via zoom meetings every two weeks. The DPCS stated the importance of all IDG members attending the meeting to discuss about the patient is so the patient receives holistic type care, making sure the patients physical, emotional and spiritual needs are all met. The DPCS further stated all IDG members do attend the meetings however she is aware that not all members are good at signing in on the IDG/POC Review in the EMR right away. The DPCS stated is the signature is missing them it means that member was not in the meeting, their part was not completed.During a concurrent interview and record review on 6/6/2025 at 1:44pm with the Administrator/Director of Patient Care Services (DPCS), Patient 5’s POC/IDG Review dated 3/13/2025, 3/27/2025, 4/10/2025, 4/24/2025, 5/8/2025, and 5/22/2025 were reviewed. Patient 5’s POC/IDG Review’s dated 3/13/2025, 3/27/2025, 4/10/2025, 4/24/2025, 5/8/2025, and 5/22/2025 indicated missing signatures from the Chaplain/Spiritual Counselor (SC) under chaplain signature section. The DPCS stated and confirmed that Patient 5’s POC/IDG Review’s dated 3/13/2025, 3/27/2025, 4/10/2025, 4/24/2025, 5/8/2025, and 5/22/2025 did not have the signature from the Chaplain/Spiritual Counselor (SC). The DPCS stated it is important that all IDG members are present during IDG meetings to provide a comprehensive outlook of the patient. The DPCS stated the electronic signature of each IDG member on the POC/IDG Review in the EMR indicates and validates their attendance and participation in the meeting.  e.     During a review of patient 8’s clinical record titled Personal Information undated, indicated a Start of Care (SOC) date of 5/1/2025, with a primary diagnosis of Dorsalgia (pain in the back, particularly mid back or upper back). During a review of Patient 8’s clinical record titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 5/29/2025, indicated an order for Skilled Nurse (SN) visit frequency of one time per week and one as needed (PRN) visit, to assess changes in condition, shortness of breath, pain and symptom management.During a review of Patient 8’s clinical records titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 5/1/2025, 5/15/2025, and 5/29/2025, Patient 8’s records indicated there was no signature for the Chaplain/Spiritual Counselor (SC) under chaplain signature section and no signature for the Medical Social Worker (MSW) under MSW Signature. During a concurrent interview and record review on 6/6/2025 at 1:50pm with the Administrator/Director of Patient Care Services (DPCS), Patient 8’s POC/IDG Review’s dated 5/1/2025, 5/15/2025, and 5/29/2025 were reviewed. Patient 8’s POC/IDG Review’s dated 5/1/2025, 5/15/2025, and 5/29/2025 indicated missing signatures from the Chaplain/Spiritual Counselor (SC) under chaplain signature section and missing signatures the Medical Social Worker (MSW) under MSW Signature. The DPCS stated and confirmed that Patient 8’s POC/IDG Review’s dated 5/1/2025, 5/15/2025, and 5/29/2025 did not have the signature from the Chaplain/SC and MSW. f.       During a review of Patient 12’s clinical record titled “Personal Information undated,” the Personal Information indicated a start of care (SOC) date of 12/6/2024, with a primary diagnosis of hypertensive heart disease without heart failure (the development of heart problems due to sustained high blood pressure, but without the heart's inability to pump blood effectively (which characterizes heart failure). It's essentially the heart's structural and functional changes (like thickening of the heart muscle) caused by prolonged high blood pressure (when the pressure in the blood vessels is too high), without the heart becoming significantly weakened or failing to pump enough blood). During a concurrent interview and record review on 6/6/2025 at 1:55 PM with the Administrator/Director of Patient Care Services (DPCS), Patient 12’s electronic health records were reviewed. The Administrator/DPCS confirmed and stated there were no Registered Nurse’s (RN) signatures on Patient 12’s “POC/IDG Review” notes, dated 4/7/2025, 4/21/2025, and 5/19/2025. The Administator/DPCS stated it was important for the RN to attend the IDG meetings and confirm attendance with a signature on the “POC/IDG Review” forms to discuss the clinical and holistic care to be provided to the patients. The Administrator/DPCS stated the RN must be able to update the IDG members regarding the patient’s understanding of the nursing care aspect.” g. During a review of patient 15’s clinical record titled admission record, undated,  it indicated a start of care (SOC) date of 11-16-23 with a terminal diagnoses of Alzheimer’s Disease is a progressive disease that alters ones ability to think and remember things clearly, it progressively gets worse over time. During a review of patient 15’s clinical record titled plan of care summary dated 6-6-25, it indicated the frequency of visits of skilled nursing (SN) is 1 per week, and Health Aide visits of (HA) 1 per week. During a review of patient 15’s clinical record titled POC/IDG reviews  dated 11-21-24, 11-7-24, and 10-24-24 indicated there was no documented evidence of an RN signature. During a phone interview on 6-6-25 at 1:30pm with the Administrator/Director of Patient Care Services (DPCS), the DPCS stated that IDG meetings are conducted every 2 weeks, in attendance are the patients MD, RN, MSW, and spiritual counselor. She stated these meetings are very important because they discuss the patient’s current condition and any future plans that they may need. She stated after each meeting everyone who attended signs the IDG note which would indicate their attendance/participation. She stated it should always be signed and it was not for patient 15 on those dates mentioned above.  h. During a review of patient 18’s clinical record titled admission record, undated, it indicated a start of care (SOC) date of      1-6-25 with a diagnosis of of Dorsalgia which refers to pain in various regions of the back including the upper, middle, or lower back. During a review of patient 18’sclinical record titled Plan of care summary dated 6-9-25 it indicated a frequency of RN visits 1/month, and SN visits 1/week During a review of patient 18’s clinical record titled POC/IDG reviews dated 5-28-25, 5-12-25, 4-28-25, 4-14-25, 3-31-25, 3-17-25, 3-3-25, 2-17-25, 2-3-25, 1-20-25, and 1-6-25 indicated there was no documented evidence of a spiritual counselor signature. During a phone interview on 6-6-25 at 1:30pm the Administrator/Director of Patient Care Services (DPCS), the DPCS stated that IDG meetings are conducted every 2 weeks, in attendance are the patients MD, RN, MSW, and spiritual counselor. She stated these meetings are very important because they discuss the patient’s current condition and any future plans that they may need. She stated after each meeting everyone who attended signs the IDG note which would indicate their attendance/participation. She stated it should always be signed and it was not for patient 18 on those dates mentioned above. During a review of the HA’s Policy and Procedure (P&P) titled Spiritual Care Counseling Services, undated, indicated the Hospice Chaplin will attend Interdisciplinary group meetings, and will work in a team approach with members of the group and other qualified professionals to evaluate patient and family/caregiver responses to care and resolution of ethical issues.  During a review of the HA’s undated policy and procedures (P&P 1), titled “Interdisciplinary Group (IDG) Meeting,” P&P 1 indicated the following:1.     The IDG must meet on a regular basis to discuss patient/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.2.     Each plan of care must be updated utilizing the results from the ongoing comprehensive assessment no less frequently that every 15 days or more frequently if the patient’s condition requires.3.     The hospice Medical Director and all hospice IDG members must be present.  During a review of the HA’s Job Description for the “Hospice Chaplain,” the Job Description indicated the following:1.     The Hospice Chaplain was responsible for the provision of spiritual care services to patients and families/caregivers, either directly or through coordination of care with other spiritual counselors.2.     The Hospice Chaplain must facilitate the development of the individualized plan of care by participating in the comprehensive assessment to meet identified spiritual needs.3.     The Hospice Chaplain must attend patient care conference and IDG meetings as a member of the IDG.4.     The Hospice Chaplain must provide consultation, education, and support to the IDG on spiritual care.  During a review of the HA’s Job Description for the “Medical Social Worker,” the Job Description indicated the following essential job functions/responsibilities:1.     Assesses the psychosocial status of patients related to the patient’s illness and environment and communicates findings to the registered nurse.2.     Carries out social evaluations and plans intervention based on evaluation findings.3.     Maintains clinical records on all patients referred to social work.4.     Participates in the development of the total plan of care and case conferences as required.Assists physician and other team members in understanding significant social and emotional factors related to health problems.

Based on interview and record review the Hospice Agency (HA) failed to follow the written Plan of Care (POC [documents the process of identifying a patient's needs and facilitating complete care and ensures collaboration among nurses, patients, and other healthcare providers]) for one of nineteen sample patients (Patient 15).a.     Missed Skilled Nurses (SN) visit for Patient 15b.    Missed supervisory RN visits for Patient 15This failure had the potential to result in Patient 15 not receive the individualized and needed services and treatments as prescribed by the physician that could have affected their overall health and well-being. --- Findings: During a review of patient 15’s “admission record” it indicated a start of care (SOC) date of 11-16-23 with a terminal diagnoses of Alzheimer's Disease is a progressive disease that alters ones ability to think and remember things clearly, it progressively gets worse over time.During a review of patient 15’s “plan of care summary” dated 6-6-25 it indicated the frequency of visits of skilled nursing (SN) is 1 per week, and Health Aide visits of (HA) 1 per week.During a review of patient 15’s “history of visit notes” with the following dates: 5-14-25 to 4-29-25, 3-16-25 to 3-2-25, 1-16-25 to 1-3-25, 11-19-24 to 11-4-24, 9-18-24 to 9-1-24, 7-17-24 to 7-1-24, 6-13-24 to 6-3-24, 1-22-24 to 1-10-24, and 12-9-23 to 11-28-23 all dates above indicated visit dates went over the ordered once per week visits.During a review of patient 15’s “history of visit notes” with the following dates: 5-24-25, to 4-7-25, 4-7-25 to 2-24-25, 2-24-25 to 12-9-24, 12-9-24 to 10-28-24, 10-28-24 to 8-26-24, 8-26-24 to 6-15-24, 6-15-24 to 4-4-24, 4-4-24 to2-23-24, 2-23-24 to 11-16-24. All dates provided indicated supervisory visits (every 2 weeks) were missed.During an interview on 6-6-25 at 1:30pm with the Administrator/Director of Patient Care Services (DPCS), Patient 15's skilled nurse visits dates were reviewed. The DPCS reviewed the dates provided on electronic medical record (EMR) of 5-14-25 to 4-29-25, 3-16-25 to 3-2-25, 1-16-25 to 1-3-25, 11-19-24 to 11-4-24, 9-18-24 to 9-1-24, 7-17-24 to 7-1-24, 6-13-24 to 6-3-24, 1-22-24 to 1-10-24, and 12-9-23 to 11-28-23, and stated and confirmed the SN visits of were missed. The DPCS was asked to see if there was any explanation of these missed visits in any communication note or narrative in the documentation, but the DPCS could not find anything and stated visits were missed with no attempt to reschedule. During a concurrent interview and record review on 6-6-25 at 1:30pm with the DPCS, Patient 15's skilled nurse visit dates were reviewed. The DPCS reviewed the dates provided on EMR for Supervisory visits of 5-24-25, to 4-7-25, 4-7-25 to 2-24-25, 2-24-25 to 12-9-24, 12-9-24 to 10-28-24, 10-28-24 to 8-26-24, 8-26-24 to 6-15-24, 6-15-24 to 4-4-24, 4-4-24 to2-23-24, 2-23-24 to 11-16-24 and the DPCS stated and confirmed the supervisory visits for Patient 15 were missed. The DPCS stated and confirmed there was no documented evidence of why the supervisory visits were not completed. The DPCS stated she could not provide a reason why visits were missed and not completed.During a review of the agency’s policy entitled Missed Visits, undated, indicated that missed visits are documented and does not affect the quality of patient care. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained. If a visit is missed and not rescheduled the clinician will notify the IDG of the missed visit and reason for missed visit. Documentation of the missed visit should be entered in the patient’s clinical record.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to meet the Condition of Participation (conditions that healthcare organizations must meet to begin and continue participating in the Medicare and Medicaid programs) for Core Services (physician services, nursing services, medical social services, and counseling services [bereavement, dietary, and spiritual])  as follows: --- 1. The HA nursing services failed to ensure that nursing needs of the patient were met as identified in the patient’s initial assessment, comprehensive assessment, and updated assessments for three of nineteen sampled patients (Patient 2, Patient 11, and Patient 14).  For Patient 2, the comprehensive assessment did not include accurate pain assessment that reflects the patient's current health status, and the nursing visit notes were signed to close by a non-clinician staff. For Patient 11 and Patient 14, the nursing notes were signed to close by a non-clinician staff.   This deficient practice had the potential to cause delay of patient care, uncontrolled patient pain, and undetected signs of physical, emotional, and spiritual needs when transitioning to final stages of dying process. (Refer to L591).  The cumulative effect of this systemic practice resulted in the failure of the hospice agency to deliver statutorily (written law) mandated compliance with Federal regulation for Core Services to ensure the highest quality of care were being provided to patients certified to receive the Medicare hospice benefits.

Based on interviews and record review, the hospice agency (HA) failed to ensure that the nursing needs of three of 19 sampled patients (Patients 2, Patient 11, and Patient 14) were met as identified in the patient’s initial assessment, comprehensive assessment, and updated assessments. a. For Patient 2, the comprehensive assessment did not include accurate pain assessment that reflects the patient's current health status, and the nursing visit notes were signed to close by HA owner who was not a licensed clinician staff and without medical background. b.  For Patient 11 and Patient 14, the nursing notes were signed to close by Intake Coordinator (IC) 1 who was not a licensed clinician staff and did not have a medical background. This failure had the potential to cause a delay in patient care delivery, uncontrolled pain, and undetected signs of physical, emotional, and spiritual needs when transitioning to the final stages of the dying process. --- Findings:a. During a review of HA’s form, titled “Personal Information,” the “Personal Information” indicated Patient 2’s Start of Care (SOC) on 1/3/2025 and End of Care (EOC) on 4/16/2025 with a primary diagnosis of malignant neoplasm of mandible (jaw/jawbone cancer). During a review of Patient 2’s History and Physical Examination (H&P), dated 8/24/2024, the H&P indicated Patient 2 had a “history of mandibular squamous carcinoma (most common type of oral cancer) who came to the hospital with failure to thrive (FTT, syndrome of progressive decline in physical and/or mental function in adults).” The H&P indicated Patient 2 had “previous tooth extractions which have shown atypical squamous cell hyperplasia (ASCH, abnormal growth of flat, scale-like cells that make up the outer layer of the skin and other tissues with atypical characteristics).” The H&P indicated Patient 2 had been “taking Tylenol (analgesic medication to relieve minor to moderate aches and pain) and hydrocodone (opioid medication to treat moderate to severe pain) without significant relief.” The H&P indicated Patient 2’s physical examination of the Head, Eyes, Ears, Nose, and Throat (HEENT) was “notable for teeth removed from lower jaw with poor healing.” During a review of Patient 2’s Comprehensive Nursing Assessment, dated 1/3/2025, the Comprehensive Nursing Assessment indicated Patient 2 was awake, alert, and oriented to time, place, and self. The Comprehensive Nursing Assessment indicated Patient 2 was “restless,” “depressed,” and experiencing “fatigue.” The Comprehensive Nursing Assessment indicated Patient 2 was “uncomfortable because of pain” and had a blood pressure of 172/98 (abnormally high) and a heart rate of 81 beats per minute. The Comprehensive Nursing Assessment indicated Patient 2’s oral cavity was “normal.” The Comprehensive Nursing Assessment indicated Patient 2 had 6/10 lower back pain and Patient 2 was instructed by Registered Nurse (RN) 1 to take Norco (pain medication combination of acetaminophen and opioid hydrocodone) 5 milligrams-325 milligrams tablet. The Comprehensive Nursing Assessment indicated RN 1 encouraged Patient 2’s caregiver to “gently massage patient’s affected area to reduce discomfort.” The Comprehensive Nursing Assessment indicated RN 1 educated Patient 2 non-pharmacological techniques, which would “help to make her condition better, such as rest, relaxation, etc.” During a review of Patient 2’s Visit Note, dated 1/10/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s VNs on 2/3/2025 “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). The Visit Note did not indicate any swelling to the jaw area. During a review of Patient 2’s Visit Note, dated 1/17/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s VNs on 2/3/2025 “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). The Visit Note did not indicate any swelling to the jaw area. During a review of Patient 2’s Visit Note, dated 1/24/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s VNs on 2/3/2025 “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). The Visit Note did not indicate any swelling to the jaw area. During a review of Patient 2’s Visit Note, dated 1/31/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s VNs on 2/3/2025 “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). The Visit Note did not indicate any swelling to the jaw area. During a review of Patient 2’s Visit Note, dated 2/7/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s VNs on 3/3/2025 “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). The Visit Note did not indicate any swelling to the jaw area. During a review of Patient 2’s Visit Note, dated 2/14/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s VNs on 3/3/2025 “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). The Visit Note did not indicate any swelling to the jaw area. During a review of Patient 2’s Visit Note, dated 2/21/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s VNs on 3/3/2025 “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). The Visit Note did not indicate any swelling to the jaw area. During a review of Patient 2’s Visit Note, dated 2/28/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s VNs on 3/3/2025 “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). The Visit Note did not indicate any swelling to the jaw area. During a review of Patient 2’s Visit Note, dated 3/7/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s VNs on 4/1/2025 “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). The Visit Note did not indicate any swelling to the jaw area. During a review of Patient 2’s Visit Note, dated 3/14/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s VNs on 4/1/2025 “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 5/10 pain and “pain patch is not helping.” The Visit Note did not indicate any swelling to the jaw area. During a review of Patient 2’s Visit Note, dated 3/28/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s VNs on 4/1/2025 “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 5/10 pain on multiple sites. The Visit Note did not indicate any swelling to the jaw area. During an interview on 6/5/2025 at 12:12 PM, Patient 2’s Family Member (FM 1) stated HA licensed nurses did not properly assess Patient 2’s jaw area swelling and pain level while Patient 2 was under their care. FM 1 stated Patient 2 developed multiple abscesses in the lower jaw area, which required hospitalization. FM 1 stated Patient 2 was “in so much pain, but nobody seemed to care and there was no pain relief.” FM 1 stated Patient 2 “couldn’t eat because of the pain.” During an interview on 6/5/2025 at 1:08 PM, Licensed Vocational Nurse (LVN) 1 stated Patient 2 always had pain level of 8/10 or 9/10 during the nursing home visits. LVN 1 stated Patient 2 had swelling to the left jaw upon admission and the swelling got “a little bigger” after a few weeks. LVN 1 stated she documented her assessments on Patient 2’s electronic health records. LVN 1 stated she did not why the Visit Notes did not reflect the pain level and the swelling to the left jaw. During a concurrent interview and record review on 6/6/2025 at 12:08 PM with the Administrator/Director of Patient Care Services (DPCS), Patient 2’s Visit Notes were reviewed. The Administrator/DPCS stated there was no documented evidence of Patient 2’s pain level of 8/10 and 9/10 and left jaw swelling. The Administrator/DPCS stated she was not aware that the HA owner was signing the Visit Notes on behalf of the licensed nurses. The Administrator/DPCS stated each licensed nurse must document and his/her assessment to validate the accuracy and completion of the Visit Notes. The DPCS stated there were no available audit logs to review.During a concurrent interview and record review on 6/6/2025 at 3:41 PM, the Administrator/DPCS stated Patient 2 was “adamant that pain pills were not going to help her.” The Administrator/DPCS stated the Visit Note, dated 3/25/2025, indicated Patient 2 “had already taken her pain medication and pain patch was applied but she is still complaining of continuous pain.” The Administrator/DPCS stated Patient 2 had mild swelling to the jaw area. b. During a review of Patient 11’s clinical record titled Personal Information undated, the Personal Information indicated a start of care (SOC) date of 11/24/2024, with a primary diagnosis of chronic obstructive pulmonary disease (a progressive lung disease that causes long-term inflammation and damage to the airways and lungs), unspecified. During a concurrent interview and record review on 6/6/2025 at 1:10 p.m., with the Administrator/Director of Patient Care Services (DPCS), Patient 11’s electronic medical record (EMR, a digital version of a patient's medical chart, containing all the information found in a traditional paper chart, but stored electronically on a computer) titled, LVN Visit Notes dated 4/21/2025, 4/28/2025, 5/5/2025, 5/12/2025, and 5/26/2025 were reviewed. The visit notes dated 4/21/2025, and 4/28/2025, indicated LVN 2 as the assigned nursing staff to conduct the nursing visit to Patient 11, but the HA’s owner, who is not a licensed clinician and without a medical background, electronically signed Patient 11’s visit notes “to close note on behalf of staff assigned” dated on 5/2/2025. The LVN Visit Notes of Patient 11, dated 5/5/2025, 5/12/2025, and 5/26/2025, indicated LVN 2 as the assigned nursing staff to conduct the nursing visit to Patient 11, but the Intake Coordinator (IC) 1, who was not a licensed clinician and without a medical background, electronically signed Patient 11’s visit notes “to close note on behalf of staff assigned” dated on 6/1/2025. The DPCS confirmed and stated that the visit notes concurrently reviewed were signed to close by the HA’s owner and the IC1 on behalf of LVN 2. The DPCS stated that HA’s owner and the IC1 were not licensed clinicians and without a medical background. The DPCS stated that the clinician assigned to conduct the assessments and documentations should sign the visit notes and not someone else. The DCPS stated that by signing the visit notes validates the documentations, and patient assessments of the clinician who conducted the visit. The DPCS stated that whoever signed a nursing visit is responsible for what is the assessments and findings documented. During a telephone interview on 6/5/2025 at 12:59 p.m. with LVN 2, LVN 2 confirmed and stated that he visited Patient 11 on the dates of 4/21/2025, 4/28/2025,5/5/2025, 5/12/2025, and 5/26/2025. LVN2 stated that he documented and submitted his assessments on each visit via electronically on his computer access. LVN 2 stated that he was unsure why his signatures were not appearing in the nursing notes. LVN 2 stated that he was not aware of the HA owner and the IC1 signing to close his visit documentations on behalf of him. LVN2 stated that it is important to sign a visit that contains his assessments of patient to validated that he visited the patient. LVN2 stated that he does not sign for any visit notes that was conducted by other nursing staff. LVN2 stated that he only signs his conducted visit documentation and stated that he did not ask for anyone to sign to close his visit notes. During a concurrent interview and record review on 6/5/2025 at 1:33 p.m. with IC1, Patient 11’s clinical records titled Visit Note LVN dated 5/5/2025, 5/12/2025, and 5/26/2025 were reviewed. Patient 11’s clinical records indicated an electronic signature by IC1. IC1 stated and confirmed she did sign Patient 11’s Visit Notes dated 5/5/2025, 5/12/2025, and 5/26/2025 to lock the notes and did not do the visits nor the documentations. IC1 stated she is not a clinician, a registered nurse, or licensed vocational nurse. IC1 stated that she only signed the visit notes to lock them but did not document in the note. IC1 stated that she made multiple calls to remind LVN2 to sign his visit notes but were not done. IC1 stated that she should have not sign it to close for other staff and she does not know that if she signs a visit notes, she will be responsible for the content of the documentation.  c. During a review of Patient 14’s clinical record titled Personal Information undated, the Personal Information indicated a SOC date of 5/25/2024 and an end of care (EOC) date of 5/31/2025, with primary diagnosis of multiple myeloma (a type of blood cancer that affects plasma cells, which are white blood cells that produce antibodies to fight infections) in relapse (a return to a previous condition after a period of improvement). During a concurrent interview and record review on 6/6/2025 at 1:19 p.m. with the Administrator/Director of Patient Care Services (DPCS), Patient 14’s EMR titled, The Discharge Summary, dated 5/31/2025 was reviewed. The discharge summary of Patient 14, dated 5/31/2025, indicated that IC1, who is not a licensed clinician and without a medical background, electronically signed “to close note on behalf of staff assigned” dated on 5/31/2025. The DPCS confirmed and stated that Patient 14’s discharge summary concurrently reviewed were signed to close by the IC1 on behalf of LVN 3. The DPCS stated that the IC1 is not licensed clinicians and without a medical background. The DPCS stated that the clinician assigned to conduct the visit, assessments and documentations should sign the discharge and not someone else. The DCPS stated that by signing the discharge summary validates the documentations, and patient assessments of the clinician who conducted the visit. The DPCS stated that whoever signed a nursing visit is responsible for what is the assessments and findings documented. During a concurrent interview and record review on 6/5/2025 at 1:37 pm with IC1, Patient 14’s clinical record titled Discharge Summary, dated 5/31/2025 was reviewed. Patient 14’s discharge summary indicated an electronic signature by IC1. IC1 stated and confirmed she did sign Patient 14’s discharge summary dated 5/31/2025. IC1 stated she signed the discharge summary to lock it, but she did not perform the visit or document in the discharge summary. IC1 stated that she made multiple calls to remind LVN3 to sign Patient 14’s discharge summary but was not done. IC1 stated that she should have not sign it to close for other staff and she does not know that if she signs a discharge summary, she will be responsible for the content of the documentation. During a telephone interview on 6/6/2025 at 11:02 a.m. with LVN3, LVN 3 confirmed and stated that he visited and documented Patient 14’s discharge summary dated 5/31/2025. LVN3 stated that he signed Patient 14’s discharge summary and submitted but might be a system error that is why his signature was not appearing in the nursing notes. LVN3 stated that he does not sign for any visit notes/discharge summary that was conducted by other nursing staff. LVN3 stated that he only signs his conducted visit documentation and stated that he did not ask for anyone to sign to close his visit notes and documentation.During a review of the HA’s undated policy and procedures (P&P), titled “Comprehensive Assessment,” the P&P indicated the following:1. The comprehensive patient assessment must be performed by the IDG no later than 5 calendar days after the election of hospice care in consultation with the attending physician.2.  All baseline data and other relevant information must be documented in the patient’s clinical record including, but is not limited to, the following:a.     Patient’s past and present medical and psychosocial history including pertinent diagnosis and any comorbiditiesb.    Patient and family/caregiver support systems and the care the family/caregiver is available, capable, and willing to provide, including applicable strengths of patient, physical, psychosocial, and/or spiritual resources available. During a review of the HA’s undated policy and procedures (P&P 2), titled “Ongoing Assessments,” P&P 2 indicated the following: During each home visit, the Case Manager or other discipline must evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment. 2. The nurse must assess the patient on each visit for a) pain, including the origin, location, duration, severity, and relief measures, b) factors that alleviate or exacerbate physical symptoms, c) current treatment related to the identified symptoms and the patient’s response, d) vital signs appropriate to the patient’s condition, e) skin integrity, f) progress towards hospice goals and patient needs and problems, and g) compliance with treatments and medication regimen. 3.  Ongoing comprehensive assessments should focus on a) patient’s response to care, b) changes in patient’s condition, level of deterioration, c) changes in patient diagnoses/prognosis, and d) changes in the patient’s care environment or support systems. 4. Based on the assessments, the plan of care—including problems, needs, goals, and outcomes—must be reviewed and update by the IDG members responsible for the case.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients {patients who have six months or less to live]) failed to ensure the Conditions of Participations (CoP-a set of minimum professional standards all home health agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) regarding Clinical Records was met as follows: --- The Hospice agency failed to ensure that the Hospice Agency Owner (OW) and Intake Coordinator 1 (IC1), who are not licensed clinicians, and without a medical background, did not sign the nurse’s visiting notes and/or the discharge summary for five of 19 sampled patients (Patient 2, Patient 7, Patient 11, Patient 14 and Patient 15). As a result of the noncompliance described above:1.      Patient 2’s nursing visit notes dated (include dates) indicated an inaccurate reflection of Patient 2’s pain levels during the home visits. Licensed Vocational Nurse 1 ( LVN1) stated she (LVN 1) had documented Patient 2’s pain level on the visit dates at a level of eight [8] out of 10 (pain rated at seven [7] or higher out of 10 indicates severe pain, on a pain scale from zero to ten where ten is the worst possible pain) for the visit notes and did not know why the documentation reflected no pain assessment and was signed by OW. 2.      Patient 2, Patient 11, and Patient 15 visit notes indicated that OW signed the visiting notes on behalf of the visiting nurses. 3.      Patient 7 and Patient 14’s discharge summary indicated that IC1signed the discharge summary on behalf of the visiting nurses.Patient 2, Patient 7, Patient 11, Patient 14 and Patient 15 were placed at increased patient safety risk due to documentation being inaccurate and or not completed by the actual clinician, which compromises continuity of care and places the patient at risk for incorrect treatment decisions, and a delay in medical care (Refer to L679).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 Clinical Records of the patients to ensure the highest quality of care were being provided to patients certified to receive the hospice benefits. a. The HA failed to ensure a completed copy of written information regarding advance directive (a legal document that outlines person's wishes in the event an individual is unable to express wishes for healthcare and treatments) policies and descriptions for one of nineteen patients (Patient 10). This failure had the potential to result in the patient’s family and/or caregivers not knowing what the patient’s medical decisions are, which can result in psychological distress to the patient/patient’s family/caregiver. (Refer to 677).b. The HA failed to ensure a discharge summary that included a summary of the patient’s stay, treatments, symptoms, current plan of care, pain management and any other documents was completed for two of nineteen sampled patients (Patient 7 and Patient 14).This deficient practice had the potential for not ensuring continuity of care was provided to patient and/or patient’s family members/caregiver after discharged. (Refer to L684). The cumulative effects 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 completed, updated, and accurately documented.

Based on interview and record review the Hospice Agency (HA) failed to ensure a completed copy of written information regarding advance directive (a legal document that outlines person's wishes in the event an individual is unable to express wishes for healthcare and treatments) policies and descriptions for one of nineteen patients (Patient 10). This failure had the potential to result in the patient’s family and/or caregivers not knowing what the patient’s medical decisions are, which can result in psychological distress to the patient/patient’s family/caregiver. --- Findings: During a review of Patient 10’s clinical record titled Personal Information, undated, the Personal Information indicated a start of care (SOC) date of 5/2/2025, with a primary diagnosis of acute ischemic heart disease (a sudden, severe reduction in blood flow to the heart muscle, leading to a lack of oxygen and nutrients), unspecified. During a review of Patient 10’s clinical record titled Plan of Care/Interdisciplinary Group Review (POC/IDG Review, a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 5/19/2025 indicated, an order for Skilled Nurse visit frequency of one time a week and one as needed (PRN) visit to assess changes of condition, shortness of breath, promote comfort, and pain and symptom management. During a review of Patient 10’s clinical record titled Current Treatment/Medication/DME (Durable Medical Equipment) List, undated, indicated, an order date of 5/2/2025 and start date of 5/2/2025 Code Status: DNR (Do Not Resuscitate, it is a medical order that instructs healthcare providers not to perform cardiopulmonary resuscitation (CPR, an emergency treatment that is done when a person’s  breathing or heartbeat has stopped) if the patient's heart stops or breathing ceases).  During a home visit observation on 6/4/2025, at 11:10 a.m., to Patient 10’s residence, with Registered Nurse (RN 1), Patient 10 was observed resting comfortably on her chair. Patient 10 is alert, awake and oriented to her name, time, place and events. During a concurrent interview and  review of Patient 10’s hospice folder with RN1, The folder had the name of the agency, inside of the folder indicated no copy of Patient 10’s POLST (Physician Orders for Life-Sustaining Treatment, is a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness). During interview with RN1, stated she was unaware that Patient 10’s POLST is not inside the hospice folder or anywhere in her residence. RN 1 stated that the POLST should always be with the patient, and it should have been check and processed by the social worker. RN 1 stated that if Patient 10’s heartbeat stops, then a CPR must perform since the POLST was not with the patient. During an interview at 11:45 a.m., with Patient 10, Patient 10 stated she does not remember if she has a copy of the POLST. Patient 10 stated she does not remember if a POLST was discussed and explained to them by the HA.During a concurrent interview and record review on 6/6/2025 at 12:45 p.m., with the Director of Patient Care Services (DPCS), indicated Patient 10’s POLST was completed but was unsure why a copy was not in Patient 10’s folder or residence. DPCS confirmed that Patient 10’s POLST, dated 5/2/2025, is complete and signed, DPCS stated that a completed copy should have been provided to Patient 10’s hospice agency’s home folder for future reference to define the code status of the patient.  During a review of the HA’s policy and procedure (P&P) titled, “Advanced Directives,” undated, the policy and procedure indicated that: 1.       Upon admission, the clinician/technician will provide information regarding a patient's right to make decisions concerning health care, which include the right to accept or refuse medical or surgical treatment, even if that treatment is life-sustaining, the right to execute Advance Directives, and applicable organization policies.  Written information designed for this purpose will be provided to the adult patient.  The clinician/technician will document in the clinical/service record that the information was provided and document all discussions concerning Advance Directives.

Based on interview and record review, the Hospice agency failed to ensure that the Hospice Agency Owner (OW) and Intake Coordinator 1 (IC1), who are not licensed clinicians, and without a medical background, did not sign the nurse’s visiting notes and/or the discharge summary for five of 19 sampled patients (Patient 2, Patient 7, Patient 11, Patient 14 and Patient 15). As a result, Patient 2, Patient 7, Patient 11, Patient 14 and Patient 15 were placed at increased patient safety risk due to documentation being inaccurate and or not completed by the actual clinician, which compromises continuity of care and places the patient at risk for incorrect treatment decisions, and a delay in medical care.On 6/6/2025, at 6:30 p.m., the Department called 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) in the presence of the two intake coordinators (Intake Coordinator 1 [IC 1] and Intake Coordinator 2 [IC 2]); and via telephone conference with the Administrator/Director of Patient Care Services (DPCS) related to the Hospice Agency's (HA- agency who provides specialized care and support for people with a serious illness who are nearing the end of life) failure to ensure that the Hospice Agency Owner (OW) and IC 1, who are not licensed clinicians and without a medical background, did not sign the nurse’s visiting notes  and or the discharge summary for five of 19 sampled patients (Patient 2, Patient 7, Patient 11, Patient 14 and Patient 15).On 6/6/2025 at 7:00 p.m., the HA was unable to submit an IJ removal plan ( IJRP- 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 6/6/2025 at 7:00pm, the Department completed the survey tasks and conducted an exit conference while onsite in the presence of IC 1 and IC 2; and via telephone conference with the Administrator/ DPCS, with the IJ not removed. --- a. During a review of Patient 2’s clinical record titled Personal Information undated, Patient 2’s Personal Information indicated, a Start of Care (SOC) date of 1/3/2025 and End of Care (EOC) date of 4/16/2025, with a primary diagnosis of malignant neoplasm of mandible (cancerous tumor that spreads to the lower jawbone).    During a review of Patient 2’s clinical record titled History and Physical Examination (H&P), dated 8/24/2024, the H&P indicated Patient 2 had a “history of mandibular squamous carcinoma (most common type of oral cancer) who came to the hospital with failure to thrive (FTT, syndrome of progressive decline in physical and/or mental function in adults).” The H&P indicated Patient 2 had “previous tooth extractions which have shown atypical squamous cell hyperplasia (ASCH, abnormal growth of flat, scale-like cells that make up the outer layer of the skin and other tissues with atypical characteristics).” The H&P indicated Patient 2 had been “taking Tylenol (analgesic medication to relieve minor to moderate aches and pain) and hydrocodone (opioid medication to treat moderate to severe pain) without significant relief.” The H&P indicated Patient 2’s physical examination of the Head, Eyes, Ears, Nose, and Throat (HEENT) was “notable for teeth removed from lower jaw with poor healing.”    During a review of Patient 2’s clinical record titled Visit Note, dated 1/10/2025, the Visit Note indicated Licensed Vocational Nurse 1 (LVN 1) conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s visit notes on 2/3/2025, and stated she signed it to close note on behalf of staff assigned. The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). The Visit Note did not indicate documented evidence of any swelling to the jaw area.    During a review of Patient 2’s clinical record titled Visit Note, dated 1/17/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s visit notes on 2/3/2025, and stated she signed it to close note on behalf of staff assigned. The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). The Visit Note did not indicate documented evidence of any swelling to the jaw area.    During a review of Patient 2’s clinical record titled Visit Note, dated 1/24/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s visit notes on 2/3/2025, and stated she signed it to close note on behalf of staff assigned. The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). The Visit Note did not indicate documented evidence of any swelling to the jaw area.    During a review of Patient 2’s clinical record titled Visit Note, dated 1/31/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s visit notes on 2/3/2025, and stated she signed it to close note on behalf of staff assigned. The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). The Visit Note did not indicate documented evidence of any swelling to the jaw area.    During a review of Patient 2’s clinical record titled Visit Note, dated 2/7/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s visit notes on 3/3/2025, and stated she signed it to close note on behalf of staff assigned. The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). The Visit Note did not indicate documented evidence of any swelling to the jaw area.    During a review of Patient 2’s Visit Note, dated 2/14/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s VNs on 3/3/2025 “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). The Visit Note did not indicate any swelling to the jaw area.    During a review of Patient 2’s Visit Note, dated 2/21/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s VNs on 3/3/2025 “to close note on behalf of staff assigned.” The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). The Visit Note did not indicate any swelling to the jaw area.    During a review of Patient 2’s clinical record titled Visit Note, dated 2/28/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s visit notes on 3/3/202, and stated she signed it to close note on behalf of staff assigned. The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). The Visit Note did not indicate documented evidence of any swelling to the jaw area.    During a review of Patient 2’s clinical record titled Visit Note, dated 3/7/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s visit notes on 4/1/2025, and stated she signed it to close note on behalf of staff assigned. The Visit Note indicated Patient 2 had 0/10 pain and did not include Patient 2’s vital signs (no temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). The Visit Note did not indicate documented evidence of any swelling to the jaw area.    During a review of Patient 2’s clinical record titled Visit Note, dated 3/14/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s visit notes on 4/1/2025, and stated she signed it to close note on behalf of staff assigned. The Visit Note indicated Patient 2 had 5/10 pain and “pain patch is not helping.” The Visit Note did not indicate documented evidence of any swelling to the jaw area.    During a review of Patient 2’s clinical record titled Visit Note, dated 3/28/2025, the Visit Note indicated LVN 1 conducted the nursing home visit, but the HA Owner electronically signed Patient 2’s visit notes on 4/1/2025, and stated she signed it to close note on behalf of staff assigned. The Visit Note indicated Patient 2 had 5/10 pain on multiple sites. The Visit Note did not indicate documented evidence of any swelling to the jaw area.    During an interview on 6/5/2025 at 12:12 PM with , Patient 2’s Family Member (FM 1), Patient 2’s FM 1 stated HA licensed nurses did not properly assess Patient 2’s jaw area swelling and pain level while Patient 2 was under their care. FM 1 stated Patient 2 developed multiple abscesses in the lower jaw area, which required hospitalization. FM 1 stated Patient 2 was “in so much pain, but nobody seemed to care and there was no pain relief.” FM 1 stated Patient 2 “couldn’t eat because of the pain.”    During an interview on 6/5/2025 at 1:08 PM with Licensed Vocational Nurse 1 (LVN 1), LVN stated Patient 2 always had pain level of 8/10 or 9/10 during the nursing home visits. LVN 1 stated Patient 2 had swelling to the left jaw upon admission and the swelling got “a little bigger” after a few weeks. LVN 1 stated she documented her assessments on Patient 2’s electronic health records. LVN 1 stated she did not why the Visit Notes did not reflect the pain level and the swelling to the left jaw.    During a concurrent interview and record review on 6/6/2025 at 12:08 PM with the Administrator/Director of Patient Care Services (DPCS), Patient 2’s Visit Notes were reviewed. The Administrator/DPCS stated there was no documented evidence of Patient 2’s pain level of 8/10 and 9/10 and left jaw swelling. The DPCS stated she was not aware that the HA owner was signing the Visit Notes on behalf of the licensed nurses. The DPCS stated each licensed nurse must document and his/her assessment to validate the accuracy and completion of the Visit Notes. The DPCS stated there were no available audit logs to review.    During a concurrent interview and record review on 6/6/2025 at 3:41 PM with the DPCS, the DPCS stated Patient 2 was “adamant that pain pills were not going to help her.” The DPCS stated the Visit Note, dated 3/25/2025, indicated Patient 2 “had already taken her pain medication and pain patch was applied but she is still complaining of continuous pain.” The DPCS stated Patient 2 had mild swelling to the jaw area.    b. During a review of Patient 7’s clinical record titled Personal Information undated, indicated a Start of Care (SOC) date of 5/2/2025 and an End of Care (EOC) date of 5/17/2025, with primary diagnosis of acute respiratory failure with hypoxia (condition where lungs cannot provide enough oxygen to the blood, leading to deficiency of oxygen in the tissues).    During a review of Patient 7’s clinical record titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 5/1/2025 indicated, an order for Skilled Nurse visit frequency of one time a week and one as needed (PRN) visit to assess changes of condition, shortness of breath, promote comfort, and pain and symptom management.   During a review of Patient 7’s clinical record titled Discharge Summary dated 5/17/2025, indicated an electronic signature from Intake Coordinator 1 (IC1) dated 5/17/2025.   During an interview on 6/5/2025 at 1:33pm with IC1, IC1 stated she is not a clinician, a registered nurse, or licensed vocational nurse. IC1 stated she does not have authority to sign documents on behalf of nurses. IC1 stated and confirmed she did sign and lock the notes for Patient 7, 11, and 14 but did not do the visit for that date or input the documentation.   During a concurrent interview and record review on 6/5/2025 at 1:39pm with IC1, Patient 7’s clinical record titled Discharge Summary dated 5/17/2025 was reviewed. Patient 7’s Discharge summary indicated an electronic signature on 5/17/2025 by IC1. IC1 stated and confirmed she did sign Patient 7’s Discharge Summary to lock it but did not document in the summary. IC1 stated the documentation in the Discharge summary was done by the visiting nurse, and she (IC1) did not do that documentation.     c. During a review of Patient 11’s clinical record titled Personal Information undated, the Personal Information indicated a start of care (SOC) date of 11/24/2024, with a primary diagnosis of chronic obstructive pulmonary disease (a progressive lung disease that causes long-term inflammation and damage to the airways and lungs), unspecified.    During a concurrent interview and record review on 6/6/2025 at 1:10 p.m., with the Administrator/Director of Patient Care Services (DPCS), Patient 11’s electronic medical record (EMR, a digital version of a patient's medical chart, containing all the information found in a traditional paper chart, but stored electronically on a computer) titled, LVN (Licensed Vocational Nurse) Visit Notes dated 4/21/2025, 4/28/2025, 5/5/2025, 5/12/2025, and 5/26/2025 were reviewed. The visit notes dated 4/21/2025, and 4/28/2025, indicated Licensed Vocational Nurse 2 (LVN 2) as the assigned nursing staff to conduct the nursing visit to Patient 11, but the HA’s owner, who is not a licensed clinician and without a medical background, electronically signed Patient 11’s visit notes “to close note on behalf of staff assigned” dated on 5/2/2025. The LVN (Licensed Vocational Nurse) Visit Notes of Patient 11, dated 5/5/2025, 5/12/2025, and 5/26/2025, indicated Licensed Vocational Nurse 2 (LVN 2) as the assigned nursing staff to conduct the nursing visit to Patient 11, but the IC1, who is not a licensed clinician and without a medical background, electronically signed Patient 11’s visit notes “to close note on behalf of staff assigned” dated on 6/1/2025. The DPCS confirmed and stated that the visit notes concurrently reviewed were signed to close by the HA’s owner and the IC1 on behalf of LVN 2. The DPCS stated that HA’s owner and the IC1 are not licensed clinicians and without a medical background. The DPCS stated that the clinician assigned to conduct the assessments and documentations should sign the visit notes and not someone else. The DCPS stated that by signing the visit notes validates the documentations, and patient assessments of the clinician who conducted the visit. The DPCS stated that whoever signed a nursing visit is responsible for what is the assessments and findings documented.   During a telephone interview on 6/5/2025 at 12:59 p.m. with Licensed Vocational Nurse 2(LVN2), LVN 2 confirmed and stated that he visited Patient 11 on the dates of 4/21/2025, 4/28/2025,5/5/2025, 5/12/2025, and 5/26/2025. LVN2 stated that he documented and submitted his assessments on each visit via electronically on his computer access. LVN 2 stated that he was unsure why his signatures were not appearing in the nursing notes. LVN 2 stated that he was not aware of the HA owner and the IC1 signing to close his visit documentations on behalf of him. LVN2 stated that it is important to sign a visit that contains his assessments of patient to validated that he visited the patient. LVN2 stated that he does not sign for any visit notes that was conducted by other nursing staff. LVN2 stated that he only signs his conducted visit documentation and stated that he did not ask for anyone to sign to close his visit notes.    During a concurrent interview and record review on 6/5/2025 at 1:33 p.m. with IC1, Patient 11’s clinical records titled Visit Note LVN dated 5/5/2025, 5/12/2025, and 5/26/2025 were reviewed. Patient 11’s clinical records indicated an electronic signature by IC1. IC1 stated and confirmed she did sign Patient 11’s Visit Notes dated 5/5/2025, 5/12/2025, and 5/26/2025 to lock the notes and did not do the visits nor the documentations. IC1 stated she is not a clinician, a registered nurse, or licensed vocational nurse. IC1 stated that she only signed the visit notes to lock them but did not document in the note. IC1 stated that she made multiple calls to remind LVN2 to sign his visit notes but were not done. IC1 stated that she should have not sign it to close for other staff and she does not know that if she signs a visit notes, she will be responsible for the content of the documentation.    d. During a review of Patient 14’s clinical record titled Personal Information undated, the Personal Information indicated a SOC date of 5/25/2024 and an end of care (EOC) date of 5/31/2025, with primary diagnosis of multiple myeloma (a type of blood cancer that affects plasma cells, which are white blood cells that produce antibodies to fight infections) in relapse (a return to a previous condition after a period of improvement).    During a concurrent interview and record review on 6/6/2025 at 1:19 p.m. with the Administrator/Director of Patient Care Services (DPCS), Patient 14’s EMR titled, The Discharge Summary, dated 5/31/2025 was reviewed. The discharge summary of Patient 14, dated 5/31/2025, indicated that IC1, who is not a licensed clinician and without a medical background, electronically signed “to close note on behalf of staff assigned” dated on 5/31/2025. The DPCS confirmed and stated that Patient 14’s discharge summary concurrently reviewed were signed to close by the IC1 on behalf of LVN 3. The DPCS stated that the IC1 is not licensed clinicians and without a medical background. The DPCS stated that the clinician assigned to conduct the visit, assessments and documentations should sign the discharge and not someone else. The DCPS stated that by signing the discharge summary validates the documentations, and patient assessments of the clinician who conducted the visit. The DPCS stated that whoever signed a nursing visit is responsible for what is the assessments and findings documented.   During a concurrent interview and record review on 6/5/2025 at 1:37 pm with IC1, Patient 14’s clinical record titled Discharge Summary, dated 5/31/2025 was reviewed. Patient 14’s discharge summary indicated an electronic signature by IC1. IC1 stated and confirmed she did sign Patient 14’s discharge summary dated 5/31/2025. IC1 stated she signed the discharge summary to lock it, but she did not perform the visit or document in the discharge summary. IC1 stated that she made multiple calls to remind Licensed Vocational Nurse 3 (LVN3) to sign Patient 14’s discharge summary but was not done. IC1 stated that she should have not sign it to close for other staff and she does not know that if she signs a discharge summary, she will be responsible for the content of the documentation.   During a telephone interview on 6/6/2025 at 11:02 a.m. with LVN3, LVN 3 confirmed and stated that he visited and documented Patient 14’s discharge summary dated 5/31/2025. LVN3 stated that he signed Patient 14’s discharge summary and submitted but might be a system error that is why his signature was not appearing in the nursing notes. LVN3 stated that he does not sign for any visit notes/discharge summary that was conducted by other nursing staff. LVN3 stated that he only signs his conducted visit documentation and stated that he did not ask for anyone to sign to close his visit notes and documentation.    e. During a review of Patient 15’s clinical record titled Personal information, undated, indicated a Start of Care (SOC) date of 11/16/23 with a primary diagnosis of Alzheimer’s Disease (a progressive disease that alters one’s ability to think and remember things clearly, it progressively gets worse over time).   During a review of patient 15’s “plan of care summary” dated 6-6-25 it indicated the frequency of visits of skilled nursing (SN) is 1 per week and health aide visits of (HA) 1 per week.  During a review of Patient 15’s clinical records titled Licensed Vocational Nurse (LVN) Visit Notes dated 1/28/2025, 2/24/2025, 2/18/2025, 2/10/2025, 2/4/2025, 3/30/2025, 3/23/2025, 3/16/2025, and 3/2/2025, indicated that the HA’s owner, who was not a licensed clinician and without a medical background, electronically signed Patient 15’s visit notes. Patient 15’s visit notes included documentation indicating the HA owner electronically signed “to close note on behalf of staff assigned.”  During a telephone interview with CEO on 6-5-25 at 11:15am, she stated that she close the nursing note for patient 15 on several occasions. She stated she never edited the note in any way but did close it out by signing it. She stated she was not a clinician and has no training in the medical field but did sign the note without making any changes to it to close it out.    During an interview on 6/5/2025 at 1:47 PM with the HA owner, the HA owner stated she signed electronically Visit Notes of LVN 1, LVN 2, LVN 3, and LVN 4 to close out the visit notes but she did not document the assessments of Patient 2, Patient 11, Patient 14, and Patient 15. The HA owner stated she has no medical background and is not a licensed nursing professional.    During a review of the HA’s policy and procedures (P&P1) titled “Submission of Clinical Record, undated, the P&P1 indicated the following: 1. The clinical record must contain sufficient information to identify the patient, describe the patient’s problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel. 2. Documentation must include, but not limited to, the following: a. Regular pain assessments, interventions, and outcomes b. Change in interventions for ineffective drug therapy or other undesired outcomes c. Attitudes and response of the patient and family/caregiver to the plan of care and services provided d. Progress towards goals/outcomes of care e. Outcome measures data elements f. Discharge summary, if applicable    3. Each entry must be dated and signed, including the title and credentials, by the person providing the care/service.   During a review of the HA agency’s policy and procedure (P&P2), titled Discharge Summary, undated, the P&P 2 indicated that all patients discharged from a service and from hospice must have a discharge summary completed and filed in the clinical record, hospice personnel who provide care will complete a discharge summary at the time the discipline is discontinued.

Based on interview and record review the Hospice Agency (HA) failed to ensure a discharge summary that included a summary of the patient’s stay, treatments, symptoms, current plan of care, pain management and any other documents was completed for two of nineteen sampled patients (Patient 7 and Patient 14). This deficient practice had the potential for not ensuring continuity of care was provided to patient and/or patient’s family members/caregiver after discharged. --- Findings: a. During a review of Patient 7’s clinical record titled Personal Information undated, indicated a Start of Care (SOC) date of 5/2/2025 and an End of Care (EOC) date of 5/17/2025, with primary diagnosis of acute respiratory failure with hypoxia (condition where lungs cannot provide enough oxygen to the blood, leading to deficiency of oxygen in the tissues).  During a review of Patient 7’s clinical record titled Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 5/1/2025 indicated, an order for Skilled Nurse visit frequency of one time a week and one as needed (PRN) visit to assess changes of condition, shortness of breath, promote comfort, and pain and symptom management. During a review of Patient 7’s clinical record titled Discharge Summary dated 5/17/2025, indicated an electronic signature from Intake Coordinator 1 (IC1) dated 5/17/2025. During an interview on 6/5/2025 at 1:33pm with IC1, IC1 stated she is not a clinician, a registered nurse, or licensed vocational nurse. IC1 stated she does not have authority to sign documents on behalf of nurses. IC1 stated and confirmed she did sign and lock the notes for Patient 7, 11, and 14 but did not do the visit for that date or input the documentation. During a concurrent interview and record review on 6/5/2025 at 1:39pm with IC1, Patient 7’s clinical record titled Discharge Summary dated 5/17/2025 was reviewed. Patient 7’s Discharge summary indicated an electronic signature on 5/17/2025 by IC1. IC1 stated and confirmed she did sign Patient 7’s Discharge Summary to lock it but did not document in the summary. IC1 stated the documentation in the Discharge summary was done by the visiting nurse, and she (IC1) did not do that documentation.     b. During a review of Patient 14’s clinical record titled Personal Information undated, the Personal Information indicated a SOC date of 5/25/2024 and an end of care (EOC) date of 5/31/2025, with primary diagnosis of multiple myeloma (a type of blood cancer that affects plasma cells, which are white blood cells that produce antibodies to fight infections) in relapse (a return to a previous condition after a period of improvement).  During a concurrent interview and record review on 6/6/2025 at 1:19 p.m. with the Administrator/Director of Patient Care Services (DPCS), Patient 14’s EMR titled, The Discharge Summary, dated 5/31/2025 was reviewed. The discharge summary of Patient 14, dated 5/31/2025, indicated that IC1, who is not a licensed clinician and without a medical background, electronically signed “to close note on behalf of staff assigned” dated on 5/31/2025. The DPCS confirmed and stated that Patient 14’s discharge summary concurrently reviewed were signed to close by the IC1 on behalf of LVN 3. The DPCS stated that the IC1 is not licensed clinicians and without a medical background. The DPCS stated that the clinician assigned to conduct the visit, assessments and documentations should sign the discharge and not someone else. The DCPS stated that by signing the discharge summary validates the documentations, and patient assessments of the clinician who conducted the visit. The DPCS stated that whoever signed a nursing visit is responsible for what is the assessments and findings documented. During a concurrent interview and record review on 6/5/2025 at 1:37 pm with IC1, Patient 14’s clinical record titled Discharge Summary, dated 5/31/2025 was reviewed. Patient 14’s discharge summary indicated an electronic signature by IC1. IC1 stated and confirmed she did sign Patient 14’s discharge summary dated 5/31/2025. IC1 stated she signed the discharge summary to lock it, but she did not perform the visit or document in the discharge summary. IC1 stated that she made multiple calls to remind Licensed Vocational Nurse 3 (LVN3) to sign Patient 14’s discharge summary but was not done. IC1 stated that she should have not sign it to close for other staff and she does not know that if she signs a discharge summary, she will be responsible for the content of the documentation. During a telephone interview on 6/6/2025 at 11:02 a.m. with LVN3, LVN 3 confirmed and stated that he visited and documented Patient 14’s discharge summary dated 5/31/2025. LVN3 stated that he signed Patient 14’s discharge summary and submitted but might be a system error that is why his signature was not appearing in the nursing notes. LVN3 stated that he does not sign for any visit notes/discharge summary that was conducted by other nursing staff. LVN3 stated that he only signs his conducted visit documentation and stated that he did not ask for anyone to sign to close his visit notes and documentation.   During a review of the HA's Policy and Procedure (P&P) titled Discharge Summary, undated, indicated that all patients discharged from services and from hospice will have a discharge summary completed and filed in the clinical record and will include date of discharge, reason for discharge, patient information, contact person receiving report, patient's physician name, health history, discharge orders/instructions, medication profile, overall status of the patient at discharge and summary of the care and services provided to the patient.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient's attending physician and hospice staff. Each patient record includes at a minimum, clinical notes that include documentation of the care and services provided. This standard was not met as evidenced by clinical record review and interview. 1 of 1 (100%) clinical record reviewed for patients receiving aide services revealed the agency did not ensure the clinical record included clinical notes that contained documentation of the aide care and services provided. Clinical Record 1: The patient elected Hospice care and was admitted for hospice services on 2/10/2023. The POC dated 2/10/2023 included orders for aide services 1 x per week. The aide visit task sheets for 2/15/2023 and 2/22/23 did not include documentation of the specific tasks that were completed by the aide during each visit. In an interview on 3/16/2023, the Director of Nursing confirmed there was no documentation of what aide tasks were performed on each visit and the agency did not have documentation of why the aide documentation was not completed.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician, a copy of the hospice discharge summary, and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. 2 of 2 (100%) clinical records reviewed of patients who revoked the election of hospice care revealed the agency did not forward a copy of the discharge summary to the patients' attending physician. Clinical Record 1: Patient was admitted to Hospice services on 2/10/2023 and revoked the election of Hospice care on 2/26/2023. The clinical record did not include evidence that a copy of the discharge summary was forwarded to the patient's attending physician. Clinical Record 4: Patient was admitted to Hospice services on 2/2/2023 and revoked the election of Hospice care on 2/15/2023. The clinical record did not include evidence that a copy of the discharge summary was forwarded to the patient's attending physician. In an interview on 3/16/2023, the Director of Nursing acknowledged there was no documentation validating that a copy of the discharge summary was provided to the patient's physician.

It is required that the Interdisciplinary Group determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in their home. The plan of care (POC) identifies the IDG’s finding regarding safe self-administration and/or family administration of drugs and biologicals. This standard was not met as evidenced by clinical record review and interview. 5 of 5 (100%) clinical records reviewed revealed the agency did not ensure that the plan of care (POC) identified the ability of the patient and/or family to safely self-administer drugs and biologicals. Clinical Record 1: The patient elected Hospice services and was admitted on 2/10/2023. The Interdisciplinary Team (IDT) POC and IDG note dated 2/10/2023 did not include documentation of the patient's and/or family's ability to safely administer drugs and/or biologicals to the patient in their home. Clinical Record 2: The patient elected Hospice services and was admitted on 2/15/2023. The IDT POC dated 2/15/2023 did not include documentation of the patient's and/or family's ability to safely administer drugs and/or biologicals to the patient in their home. Clinical Record 3: The patient elected Hospice services and was admitted on 2/26/2023. The IDT POC dated 2/26/2023 did not include documentation of the patient's and/or family's ability to safely administer drugs and/or biologicals to the patient in their home. Clinical Record 4: The patient elected Hospice services and was admitted 2/2/2023. The IDT POC dated 2/2/2023 did not include documentation of the patient's and/or family's ability to safely administer drugs and/or biologicals to the patient in their home. Clinical Record 5: The patient elected Hospice services and was admitted on 3/01/2023. The IDT POC dated 3/01/2023 did not include documentation of the patient's and/or family's ability to safely administer drugs and/or biologicals to the patient in their home. During an interview on 03/16/2023, the Director of Nursing confirmed there was no documentation in the patients' plans of care or IDG notes stating the patient's/family's ability to safely administer drugs and/or biological in their home.